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Population awareness of tobacco-related harms: implications for refreshing graphic health warnings in Australia

Emily Brennan, Kimberley Dunstone and Melanie Wakefield
Med J Aust || doi: 10.5694/mja17.01207
Published online: 9 July 2018

Tobacco harms most organs,1 and is the leading single cause of preventable deaths in Australia.2 Graphic health warnings (GHWs) on tobacco products are a critical component of comprehensive tobacco control programs,3 and highly cost-effective for increasing knowledge about the harms of tobacco.4 GHWs require updating regularly to maintain salience and impact.3 As attendees of the 2017 Oceania Tobacco Control Conference learned, the Australian government is therefore reviewing the GHWs that have been on packs since 2012.5 Central to GHW policies is the question of which harms should be highlighted. One important factor in this decision is population awareness of tobacco-related harms, and identifying those with the greatest potential for knowledge gains.

In September 2017, we surveyed awareness of 23 health conditions causally associated with tobacco use.1 We recruited a representative sample of Australians aged 18–69 years (1806 participants after sample weighting by sex, age by highest educational attainment, state by part of state, country of birth, telephone status [number of landlines in household, number of mobile phones owned by respondent], internet usage and frequency, number of adults in household, and an enrolment weight) from a probability-based online panel (2578 eligible members; survey completion rate, 70.1%).6 The population covered by the panel included all Australian adults contactable by landline or mobile phones, including those without internet access.6 Participants completed the survey online (92%) or by telephone (8%). The cumulative response rate was 10.3%, incorporating the response rate from the recruitment phase (15.5%), unavailability in the survey month, and attrition after establishment of the panel.6 Weights were calculated for each respondent and applied to all analyses. The Institutional Research Review Committee of Cancer Council Victoria provided ethics approval (reference, IER 1609); participant consent was obtained at survey commencement.

Participants were asked, “If you smoke, how likely is it that you will increase your risk of …”. Responses of “very likely” and “likely” were combined and compared with the combined responses of “neither likely nor unlikely”, “unlikely”, “very unlikely”, “not sure”, and “prefer not to say”. We report awareness overall, and for current, former and never smokers; the effectiveness of GHWs may be increased if these messages encourage never smokers to initiate conversations with family and friends.7

The proportion of respondents aware that smoking increases risk ranged between 27.1% for rheumatoid arthritis and 91.2% for lung cancer (Box). Only nine of the 23 conditions were endorsed by more than two-thirds of the sample; six cancers were endorsed by fewer than two-thirds. Endorsement of harms featured in GHWs in Australia during the preceding 5 years under the Competition and Consumer (Tobacco) Information Standard 20118 was significantly higher than for those that were not, both overall (73.5% v 48.9%; P < 0.001) and among smokers (67.5% v 39.5%; P < 0.001).

Awareness was generally highest among never smokers, but the relative ordering of the 23 conditions from highest to lowest awareness was similar for all groups (Spearman rank order correlation for each comparison, > 0.90; P < 0.001), indicating that the conditions with greatest potential for knowledge gains are the same for never, former, and current smokers.

These findings reveal the limited awareness of many serious harms of tobacco, and the considerable potential for further educating Australians. Our findings can assist policy makers identify harms for which the potential for knowledge gains is greatest. While we did not define or explain harms, and low awareness may in some cases reflect a lack of understanding, well designed GHWs can include images and texts that increase both the awareness and understanding of specific harms.

Box – Awareness of Australian adults of health conditions caused by smoking: number who responded “very likely” or “likely” for each condition

 

Total

Smoking status*


Never smokers

Former smokers

Current smokers


Number of respondents

1806

958

471

363

Lung cancer

1646 (91.2%)

897 (93.6%)

432 (91.8%)

304 (83.9%)

Throat cancer

1615 (89.4%)

885 (92.4%)

423 (90.4%)

295 (81.4%)

Mouth cancer

1586 (87.8%)

870 (90.8%)

419 (88.9%)

286 (78.8%)

Disease of the teeth and gums

1574 (87.1%)

862 (90.0%)

411 (87.2%)

291 (80.2%)

Heart disease

1549 (85.8%)

834 (87.0%)

418 (88.8%)

288 (79.3%)

Emphysema

1546 (85.6%)

820 (85.7%)

421 (89.5%)

294 (81.0%)

Stroke

1490 (82.5%)

799 (83.5%)

411 (87.4%)

271 (74.7%)

Oesophageal cancer

1391 (77.0%)

778 (81.2%)

365 (77.5%)

243 (66.9%)

Poor outcomes after surgery

1341 (74.3%)

769 (80.3%)

359 (76.2%)

207 (57.0%)

Peripheral vascular disease

1162 (64.4%)

626 (65.3%)

330 (70.1%)

202 (55.6%)

Stomach cancer

1021 (56.5%)

577 (60.2%)

271 (57.6%)

167 (46.2%)

Pancreatic cancer

921 (51.0%)

529 (55.2%)

222 (47.1%)

164 (45.3%)

Liver cancer

912 (50.5%)

535 (55.8%)

226 (47.9%)

146 (40.1%)

Infertility in women

899 (49.8%)

548 (57.3%)

212 (45.0%)

135 (37.2%)

Kidney cancer

864 (47.8%)

478 (49.9%)

229 (48.5%)

151 (41.6%)

Peptic ulcer

859 (47.6%)

489 (51.0%)

222 (47.0%)

143 (39.4%)

Erectile dysfunction in men

808 (44.7%)

494 (51.6%)

189 (40.2%)

120 (33.1%)

Blindness

786 (43.5%)

395 (41.3%)

229 (48.6%)

159 (44.0%)

Bladder cancer

750 (41.5%)

404 (42.2%)

192 (40.8%)

151 (41.6%)

Diabetes

726 (40.2%)

412 (43.0%)

192 (40.8%)

118 (32.4%)

Ectopic pregnancy

655 (36.3%)

402 (43.0%)

140 (29.7%)

101 (27.7%)

Acute leukaemia

562 (31.1%)

326 (34.1%)

141 (29.9%)

93 (25.6%)

Rheumatoid arthritis

489 (27.1%)

290 (30.2%)

109 (23.2%)

88 (24.2%)


* Never smokers have not smoked 100 cigarettes in their lifetime, former smokers have smoked 100 cigarettes but do not currently smoke, and current smokers said that they currently smoked daily, weekly, or less than weekly. Smoking status was missing for 15 participants. † Respondents were asked, “How likely do you think it is that smoking increases the risk of…?” Bold: Harms featured on graphic health warnings in Australia in the 5 years before the survey; in September 2017, any of 14 designated GHWs could be displayed on cigarette packs. All raw numbers are weighted as described in the text.

Received 5 December 2017, accepted 15 March 2018

  • Emily Brennan
  • Kimberley Dunstone
  • Melanie Wakefield

  • Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, VIC


Acknowledgements: 

This research was supported a National Health and Medical Research Council Project Grant (1129002). We acknowledge the contribution to survey design made by Michelle Scollo, Cancer Council Victoria. Melanie Wakefield holds an NHMRC Principal Research Fellowship.

Competing interests:

We are employed by the non-government organisation, Cancer Council Victoria, which has a charter for conducting science-based cancer control.

  • 1. United States Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta (GA): USDHHS; Centers for Disease Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion; Office on Smoking and Health, 2017. https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm (viewed Nov 2017).
  • 2. Australian Institute of Health and Welfare. Risk factors contributing to chronic disease (AIHW Cat. No. PHE 157). Canberra: AIHW, 2012.
  • 3. World Health Organization. WHO Framework Convention on Tobacco Control. Guidelines for implementation: article 5.3; article 8; articles 9 and 10; article 11; article 12; article 13; article 14. Geneva: WHO, 2013. http://apps.who.int/iris/bitstream/10665/80510/1/9789241505185_eng.pdf (viewed May 2018).
  • 4. Noar SM, Francis DB, Bridges C, et al. The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies. Soc Sci Med 2016; 164: 118-129.
  • 5. Masri G. Collaboration with government: a recipe for success in tobacco control (closing plenary) [unpublished presentation]. Oceania Tobacco Control Conference, Hobart, 17–19 October 2017.
  • 6. Social Research Centre (Australian National University). Life in Australia panel. 2017. http://www.srcentre.com.au/our-research/life-in-australia-panel (viewed Nov 2017).
  • 7. Thrasher J, Abad-Vivero EN, Huang L, et al. Interpersonal communication about pictorial health warnings on cigarette packages: policy-related influences and relationships with smoking cessation attempts. Soc Sci Med 2016; 164: 141-149.
  • 8. Australian Government. Competition and Consumer (Tobacco) Information Standard 2011. Federal Register of Legislation, 7 Feb 2012. https://www.legislation.gov.au/Details/F2011L02766 (viewed May 2018).

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