The impact of pictorial health warnings (PHWs) and testimonial of cancer patients on smoking behaviour among adults and adolescents in the state of Pahang

Abstract

Tobacco use being the most preventable cause of premature death. Tobacco is responsible for almost 6 million deaths worldwide in 2011 and 80% of the deaths come from low- and middle- income countries. In line with Article 11 and Article 12 of the World Health Organization Framework Convention of Tobacco Control (WHO FCTC) the combined use of Pictorial Health Warnings (PHWs), media advertising and quit-line is found to be synergistic and cost-effective. Malaysia implemented the PHWs on 1st June 2009 which carried warnings depicting graphically health consequences of smoking on the cigarette packages but no advertisement with personal testimonial of actual tobacco-related cancer patient was yet produced. This study was conducted to evaluate the impact of PHWs on Malaysian cigarette packs quantitatively as well as on a newly developed personal testimonial of tobacco-related cancer patient using focus group discussion. A prospective, longitudinal survey was undertaken with a total of 526 subjects (154 adults and 372 adolescents). 41.6% and 20.4% of adults and adolescents respectively, were smokers. Baseline survey and follow-up was done six months after the official date of PHWs implementation using self-administered questionnaires. Findings revealed 34% (n=18) of 53 adults and 37.8% (n=17) of 45 adolescents who were smoked at baseline reported to stop smoking at follow-up. An increasing trend was shown in all four measures on cognitive responses towards the new PHWs compared to old text-only HW in which PHWs at baseline vs. text-only HW increased significantly in noticing, looked or read closely, talked about, and thought about the warnings in adolescents (X2(2)=13.806, p<0.05; X2(2)=16.543, p<0.001; X2(2)=12.860, p<0.05; X2(2)=8.115, p<0.05), respectively. On the other hand, there are significant changes over the two different types of warnings among adults to frequently looked closely (X2(2)=8.259, p<0.05), talked about (X2(2)=24.065, p<0.001) and thought about the health warning (X2(2)=35.108, p<0.001). Positive responses were obtained on perceived effectiveness of PHWs among both adults and adolescents on all five measures i.e. quit intention, reduced cigarette consumption, quit attempt, and encouraged quitting and smoking prevention. An unscripted personal testimonial of a neck cancer survivor was then evaluated qualitatively using Focus Group Discussion (FGD). Using Braun and Clarke’s (2006) thematic analyses in reviewing and interpreting the transcripts, majority of smokers and non-smokers agreed the testimonial was able to elicit negative emotions and identify with the patient. Regardless of smoking status and age group, participants considered the testimonial to be highly effective to increase awareness on the danger of smoking, in encouraging them to quit and in preventing cigarette uptake among adolescents. Study findings provide further evidence to support the use of ‘personal testimonial’ as an anti-smoking advertisement in concert with PHWs in educating and promoting quitting as well as preventing cigarette uptake among adolescents. However, several aspects of the testimonial need to be improvised to ensure maximum impact.