Demographic characteristics, nicotine dependence, and motivation to quit as possible determinants of smoking behaviors and acceptability of shocking warnings in Italy.

INTRODUCTION: This paper presents the final results of a cross-sectional study started in 2010. It compares the perceived efficacy of different types of tobacco health warning (texts versus shocking pictures) to quit or reduce tobacco use. METHODS: The study conducted between 2010 and 2012 in Italy enrolled adults smokers. Administering a questionnaire demographic data, smokers behaviors were collected. Showing text and graphic warnings (the corpse of a smoker, diseased lungs, etc.) the most perceived efficacy to reduce tobacco consumption or to encourage was quit. RESULTS: 666 subjects were interviewed; 6% of responders referred that they stopped smoking at least one month due to the textual warnings. The 81% of the smokers perceived that the warnings with shocking pictures are more effective in reducing/quitting tobacco consumption than text-only warnings. The younger group (<45 years), who are more motivated to quit (Mondor's score ≥ 12), and females showed a higher effectiveness of shocking warnings to reduce tobacco consumption of, 76%, 78%, and 43%, respectively with P < 0.05. CONCLUSIONS: This study suggests that pictorial warnings on cigarette packages are more likely to be noticed and rated as effective by Italian smokers. Female and younger smokers appear to be more involved by shock images. The jarring warnings also appear to be supporting those who want to quit smoking. This type of supportive information in Italy may become increasingly important for helping smokers to change their behavior.

[Impact of cigarette packages warning labels in relation to tobacco-smoking dependence and motivation to quit]. / Impatto delle avvertenze riportate sui pacchetti di sigarette in funzione della dipendenza dal fumo di tabacco e del desiderio di smettere in un campione di fumatori.

OBJECTIVE: the principal aim was to assess the impact of health warnings on cigarette packages in Italy, the reduction of daily number of cigarette smoked, in relationship to the tobacco-smoking dependence and motivation to quit. The second aim was to compare the impact of text warnings versus graphi depictions. DESIGN: cross-sectional study (survey). SETTING AND PARTICIPANTS: the study was conducted through interviews to an opportunistic sample of smokers.The subject enrolled were adult smokers (years ≥ 18), living in the province of Rome. Data were collected in two outpatient clinics located in Morlupo and Rome. Interviews were administered in the waiting rooms, to patients or to their relatives/ helpers. The survey was conducted in June-September 2010. The sample size (266 participants) was computed using a power of 80%, a confidence level of 95%, an expected frequency of smokers with a low motivation to quit who reduced number of cigarettes due to warnings of 15%, and a frequency of smokers with a higher motivation to quit who reduced number of cigarettes due to warnings of 30%. MAIN OUTCOME MEASURES: the effect of the health warnings used in Italy on smoking reduction was measured with the following self-reported items: "Are you or have you been influenced by the health warnings on cigarettes packages (in relation to the daily number of cigarettes smoked)?"; "Have you changed your smoking habits due to the warnings (for example: don't smoking after a coffee.)?"; "Have you ever stopped smoking due to the warnings?" The effect of labels that used shock images on cigarette boxes was measured using followed self-reported questions: "If shocking images were used on cigarette boxes, would they have greater effect than simple warning text currently used?"; "If your favourite cigarettes brand decide to change the look of its cigarette boxes with shocking images on smoking health damages, would you be driven to change it?" RESULTS: thanks to the health warnings, 95% of the 270 participants were informed on smoking damages, 14% (34 smokers) reduced the number cigarettes per day, and 5% (12 smokers) attempted to quit. Forty-five percent of smokers did not know the real impact of light cigarettes on their health, and 49% decided to smoke light cigarettes after having read the warnings. Women were more susceptible to immediate consequences of smoking (appearance of wrinkles; p<0.001), and were more prone to switch to light cigarettes (p=0.002). Smoking dependence, computed with Fagerstrom's test, showed significant differences by age groups (higher in smokers aged 30-45 years; p=0.001), and in smokers who were not interested to deepen knowledge of smoking effects (p=0.009). Individuals more motivated to quit were younger smokers (p=0.012). Smokers aged ≥ 45 years (OR=2.54; 95%CI 1.05-6.17), more motivated to quit (OR=2.92; 95%CI 1.17-7.30), those who reported they do not like the smoking smell on their own clothes (OR=3.6; 95%CI 1.4-9.0), those who reported warning messages are important (OR=4.93; 95%CI 1.55-15.71), those who changed their own smoking behavior due the warnings (OR=3.31; 95%CI 1.10-9.99) were more likely to reduce daily number of cigarettes due the health warnings. Forty-seven percent thought that health warnings with text and images could have a higher impact in comparison to text-only warnings. Moreover, women were more motivated to change cigarette brand if a brand should introduce pictorial warnings (OR=2.54; 95%CI 1.41-4.56). CONCLUSION: our study showed some positive effects of the introduction of health warnings on cigarette packages. In fact, almost all were informed on tobacco effects, 14% of them reduced the amount of daily smoking, and 5% attempted to quit. Many smokers still believe that switching to lighter cigarettes (e.g. those with less nicotine and tar contents) reduces smoking-related diseases. More than 50% of smokers recognized the importance of health warnings in communicating health risks of smoking, while women were more impressed than men by shocking pictorial warnings.