Warning Labels Help Ex-Smokers Resist

  • by Staff Writer, MedPage Today

Action Points

  • This study found that former smokers can be helped with avoiding relapse if they actively pay attention to the health-risk warning labels on cigarette packs.
  • Note that country of residence did not significantly predict relapse, even though the warning labels in the United Staates are text only and placed on the side of the pack, whereas in the other countries the labels are larger, placed more prominently, and can include graphic illustrations.

Health-risk warning labels on cigarette packages can help former smokers avoid relapse -- if they actively use them as part of a strategy to remain tobacco-free, a prospective cohort survey suggested.

In a series of multivariate analyses, merely noticing the warning labels was actually associated with a greater risk of relapse (OR 1.52, 95% CI 1.11 to 2.09, P<0.01) according to Ron Borland, PhD, of the Cancer Council Victoria, in Carlton, Australia, and colleagues.

"Mere exposure to the warnings, because it entails concurrent exposure to cigarettes, is likely to be positively associated with relapse," they explained online in Tobacco Control.

However, after controlling for the factors of self-efficacy for remaining abstinent and the degree of urge to smoke, the greater risk was no longer present (OR 1.29, 95% CI 0.92 to 1.80, P=0.135), they reported.

"We theorize that the mechanism by which [warning labels] help ex-smokers to stay quit involves some sort of active use of the warnings, for example, to help generate reasons for resisting temptations to relapse, and is not something that occurs automatically," the investigators wrote. "We therefore speculate that the individuals who report that [warning labels] will help them a lot to stay quit have (consciously or not) devised strategies to use them to do exactly that."

Previous research has shown that the presence of warning labels on cigarette packs helps nonsmokers avoid the habit, but it has not been determined what effects the warnings have on ex-smokers.

To evaluate this, the researchers enrolled 1,936 individuals who had quit within the previous year from the International Tobacco Control 4-Country project, a longitudinal annual survey of smokers in the United States, Canada, the United Kingdom, and Australia.

Participants' average age was 46, and slightly more than half were women.

A total of 57.5% of participants who had quit reported that they were still not smoking after a year.

In a structured telephone interview, participants were asked how often in the previous 30 days they had noticed a warning label on a pack of cigarettes, with possible responses being "never, rarely, sometimes, often, or very often."

They also were asked to what extent warning labels caused them to consider the risks of smoking on their health, with possible responses of "not at all, a little, somewhat, or a lot."

A third question was to what extent the labels influence them to remain abstinent, with the same possible responses as for the previous question.

Former smokers who reported that warning labels caused them to be "a lot" more likely to remain abstinent had relapse rates of 41%, while those who said that the labels caused them to be "not at all" more likely to refrain from smoking had relapse rates of 50%, the researchers reported.

These rates reflected adjustment for tobacco exposure, strength of the urge to smoke, self-efficacy, and degree of former dependence on cigarettes.

"Given that self-efficacy and frequency of urges have been shown to mediate the effects of most other possible determinants of relapse, this is a notable reduction in relapse," they stated.

Country of residence did not significantly predict relapse, even though the warning labels differ markedly.

For instance, in the United States, the warning labels are text only and are placed on the side of the pack, whereas in the other countries the labels are larger, placed more prominently, and can include graphic illustrations.

But when the researchers analyzed the indirect effects of the size, type, and novelty of the labels, they found that both size (OR 1.56, 95% CI 1.14 to 2.13, P<0.01) and novelty (OR 1.26, 95% CI 1.15 to 1.38, P<0.001) were associated with participants' remaining abstinent.

The researchers suggested that the ex-smokers who reported that the warnings helped them avoid cigarettes use the labels to deliberately think of reasons to not smoke. Accordingly, they encouraged healthcare providers to advise former smokers to actively focus on warning labels during times of temptation to help them resist their urges.

These findings should be interpreted with caution, however, because participants who reported using the labels to help them may have been a more highly motivated group, the researchers noted.

The survey is supported bythe Roswell Park Cancer Institute, the National Cancer Institute, the Robert Wood Johnson Foundation, the Canadian Institutes of Health Research, the National Health and Medical Research Council of Australia, Cancer Research UK, the Canadian Tobacco Control Research Initiative, the Center for Behavioral Research and Program Evaluation, and the National Cancer Institute of Canada.

The researchers reported no competing interests.

  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner