Full length articleUsing eye-tracking to examine how embedding risk corrective statements improves cigarette risk beliefs: Implications for tobacco regulatory policy
Introduction
An increased public awareness of health risks of smoking has led the tobacco industry to develop “new” products that have been marketed as less harmful than regular cigarettes. The development, advertising and marketing of “new” products started with the promotion of light cigarettes in the 1960s (National Cancer Institute, 2001), and continued with the marketing of potentially reduced exposure products (PREPs), to the most recent marketing of Modified Risk Tobacco Products (MRTPs), which are often developed as lower tar/nicotine cigarettes (Dunsby and Bero, 2004, U.S. Department of Health Human Services, 2000). In the aggressive marketing of harm reduction, tobacco companies have effectively used cigarette pack design, colors, labels and descriptive terms to communicate strength, harshness, lower nicotine, tar levels and risk of their products (Anderson et al., 2006, Bansal-Travers et al., 2011, Philip Morris, 1981, Pollay and Dewhirst, 2001, Pollay and Dewhirst, 2002, Slade, 1997, Wakefield et al., 2002).
While previous efforts under the Tobacco Control Act (TCA) have successfully mandated removal of descriptive terms, other actions to convey health information to consumers, for example the implementation of graphic warning labels, have been upheld by U.S. federal courts. Given evidence that many smokers misinterpret the information contained in cigarette marketing and perceive a modified type of cigarette as safer or having lower health risks than regular cigarettes (Hamilton et al., 2004, O’Connor et al., 2005, Parascandola et al., 2009, Shadel et al., 2006, Shiffman et al., 2007, Shiffman et al., 2004), it is important to develop more accurate advertising and to counter misinformation in order to better inform smokers of their risks. This correction of misinformation in advertisements calls for and requires a better understanding of how accurate information can be conveyed to smokers. The TCA empowered the Food and Drug Administration (FDA) to review MRTPs to ensure that marketing and advertising claims are supported by scientific evidence and are not misleading (U.S. FDA Center for Tobacco Products, 2015). Further, in 2006, the U.S. District Court ordered the use of corrective statements in advertising and promotion to correct past deceptive practices of the tobacco companies and to enhance knowledge among consumers (Smith et al., 2011, U.S. District Court DC. U.S. v. Philip Morris USA, 2006).
Few studies have investigated the effects of counter-advertising and corrective messages on risk perception of cigarette products (Biener et al., 2007, Kozlowski et al., 2001, Kozlowski et al., 1999, Kozlowski et al., 2000, Shiffman et al., 2001, Strasser et al., 2008, Tangari et al., 2010). Some studies demonstrated that counter-marketing ads on TV (Kozlowski et al., 2000) and radio (Kozlowski et al., 2001, Kozlowski et al., 1999) can improve the risk perception of light cigarettes, and that corrective print advertisements can influence consumers’ beliefs about smoking (Tangari et al., 2010). With regard to correctives in print advertisements, Biener et al. (2007) found that providing health information (adding explicit content) in the form of a box at the bottom of print advertisements had only little impact on the risk perception of the product. It remains unknown whether and how much attention smokers paid to the health information that was provided in a box similar to a text warning label at the bottom of the ad. Previous research has shown that viewers rarely focus on a text warning label (Fischer et al., 1989, Munafò et al., 2011). Given these results and the fact that the center of the ad is viewed more attentively (Strasser et al., 2012), integrating explicit corrective text messages in the body of the ad might be a more effective strategy. In a study where smokers were either exposed to the original Quest print advertisement, an ad in which the cigarette packages were altered to the color red (altering implicit content), or an ad where all text was removed from the ad (removing explicit content), it was found that removing the text affects beliefs about the harmfulness of the product (Strasser et al., 2008). Smokers who were exposed to the altered implicit ad did not report fewer false beliefs about the harmfulness of the product than smokers exposed to the original advertisement. It is plausible but remains unknown whether an ad with combined explicit and implicit accurate content would be associated with a more accurate understanding of harm exposure.
These studies demonstrate that the risk perception of a product can be corrected by altering explicit and implicit content of the ad. However, it remains unclear whether adding explicit accurate information (i.e., a corrective statement about product risk) in the body of the ad and altering implicit information (i.e., cigarette package color) affects smokers’ risk perception of the product. Therefore, using a 2(explicit/implicit) × 2(accurate/misleading) between-subject design, we investigated the effect of manipulating advertisement content on smokers’ false beliefs about the product and smokers’ recall of explicit and implicit information after viewing the advertisements. The manipulated explicit factor was the inclusion of a text corrective about tar and nicotine content which has been shown to have a sustained effect on perceived product risk (Kozlowski and Sweeney, 1997). The manipulation of the cigarette package color and background images that have been shown to impact risk perception and have been increasingly used to imply health claims (Bansal-Travers et al., 2011) were examined as an implicit factor.
Additionally, to better understand how smokers view implicit and explicit content, we assessed attention to different parts of the advertisement using eye-tracking. We hypothesized that smokers who were exposed to the explicit and implicit accurate ads, compared to those exposed to the misleading ads, will report fewer false beliefs about the product and will better recall the information stated by the corrective. The results of the present study will provide valuable information on what content of the advertisement draws attention, what content distract smokers from viewing health information, where corrective health information needs to be placed in an ad, and how implicit and explicit information in cigarette advertisements affect risk beliefs about nicotine products. Given the continuous introduction of nicotine-containing products (e.g., low nicotine cigarettes, little cigars, e-cigarettes) and the significant marketing of these products, it is critical that regulatory efforts are aware of how product users can be mislead.
Section snippets
Sample and procedure
A total of 203 current smokers participated in the study. Inclusion criteria were: currently smoking a minimum of 10 cigarettes/day (non-menthol) for a minimum of 5 years; not currently trying to quit or intending to do so in the next two months; between 21 and 65 years old; speaking English fluently; no current substance abuse; no visual impairments. Participants responding to advertisements were screened for eligibility by telephone and those deemed eligible were scheduled. The study
Descriptive statistics and randomization verification
Table 1 displays sample characteristics by condition. Participants were on average 30.6 years old (SD = 8.07; range = 21–58). The sample was predominantly male (64.5%) and Caucasian (92%). Most participants had completed a high school degree (98%); 39.4% had completed college. Participants on average reported smoking for 12.86 years (SD = 6.8), and smoking 16.6 cigarettes/day (SD = 5.7), and an average nicotine dependence score of 5.1 (SD = 2.1). The most popular brands were Marlboro (41.7%), Camel
Discussion
This study examined whether the correction of explicit and implicit content of an advertisement affects attention to the ad, false beliefs about the product, and recall of information provided by the ad. Results indicate that smokers focus relatively early in their viewing pattern on an explicit text corrective that was embedded in the body of the ad. In addition, exposure to the corrective statement improves smokers’ beliefs about the harmfulness of the product and recall of the information
Conflict of interests
No conflict declared.
Role of funding source
Research reported in this publication was supported by the National Cancer Institute (NCI) of the National Institutes of Health (NIH) and FDA Center for Tobacco Products (CTP) under Award Numbers P50CA179546, and R01CA180929, as well as Robert Wood Johnson Foundation 62622. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration (FDA). The funding sources had no role in the study design, in the
Contributors
Andrew A. Strasser conceived and supervised the study. Kirsten Lochbuehler completed the analyses. Kirsten Lochbuehler led the writing. Kathy Z. Tang, Valentina Souprountchouk, Dana Campetti, Joseph N. Cappella, and Lynn Kozlowski assisted with the study. All authors have approved the final article.
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