Comparing Health Warnings in China to

Health Warnings in Other Countries:

An experimental study in four Chinese cities
Geoffrey T. Fong, David Hammond, Pete Driezen, & Anne C.K. Quah
University of Waterloo
Jiang Yuan and Li Qiang
China Center for Disease Control and Prevention

February 18, 2009

gfong@uwaterloo.ca
http://www.itcproject.org 1
The Importance of Package Warnings/Labelling

 Package warnings: an excellent method for informing people

about the harms of tobacco use and of smoke constituents
 Package warnings = a health information intervention:
Smoker who smokes 20 cigarettes/day:
1. Potentially exposed 7,300 times to the warnings
2. In times and situations that are relevant to the behavior:
– When buying cigarettes
– When getting a cigarette out of the pack

There are probably NO other interventions in health that

are delivered so often and in such an appropriate way.
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 FCTC Article 11

 Minimal Standard: 30% on front and back, text-only

 Recommended: 50% on front and back, with pictures

 Warnings must be rotated

 Strong Guidelines for Article 11 adopted at the Third

Conference of the Parties (Nov 2008, Durban, South Africa)

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 Health Warnings in China

Until October 2008,

China had U.S.-style
warnings: on side of
the pack and barely
noticeable. The ITC
China Survey data
confirm the very low
impact of the China
warnings on key
indicators of warning
effectiveness

From ITC China Summary

February 2009 4
China’s warning labels changed in Oct 2008

OLD warning: NEW warnings:

Side of pack Front/back of pack
Only one message Two messages 5
 Front of Pack: Back of Pack:
Two very general Repeats the front
messages but in English!! 6
Summary Table of the New Chinese Warnings With
Respect to the Article 11 Guidelines

Guideline YES NO
1 Should appear on both front and back ?
2 Should be at the TOP of the package
3 Should be as large as possible (at least 50%)
4 Should include full colour pictures
5 Should rotate multiple messages
6 Should include a range of warnings and
messages
7 Should include info on harmful effects of
tobacco smoke
8 Should provide advice about cessation
9 Should list constituents without numbers

Guideline #1 is a question mark because the

warning on the back of the pack is in English
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 Study Outline

 Main objective: To compare the Chinese warnings (old

and new) in effectiveness to those of other countries.
 We created high-quality photos of warnings from other
countries as they might appear if they were put on Chinese
packs, consistent with the Article 11 Guidelines.
 We showed the old and new Chinese warnings, along with
8 other possible warnings from other countries and had
people from 4 cities make judgments about each of the
warnings.
 Used established methods from psychology and from
marketing research in the study
 Careful controls were used to be able to make strong
conclusions (e.g., the same brand was used for each
created warning) 8
 Participants

The study was conducted in four cities in China: Beijing, Shanghai,

Kunming, and Yinchuan. In each city, there were close to 300 participants.
The total number of participants by type in each of the 4 cities was:

Adult Adult Youth

Smoker Non-Smoker (13-17 years) TOTAL
City Male Female Male Female Male Female
Beijing 55 40 39 47 51 45 277
Kunming 50 50 46 50 50 50 296
Shanghai 51 52 47 50 50 50 300
Yinchuan 50 48 48 50 50 50 296
TOTALS 206 190 180 197 201 195 1169

Within each of the adult categories, the participants were approximately

evenly distributed across ages: (a) 18-29 years old, (b) 30-39 years old,
(c) 40-49 years old, (d) 50+ years old.

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 Stimulus Materials

Stimulus Materials

10 images of Chinese HWLs were created, including the OLD

Chinese HWL (U.S. style: on the side of the pack and
insignificant) and the NEW Chinese HWL (30% on the front of the
pack, but not very distinctive). We created 8 other Chinese HWLs
(through Photoshop) so that the actual Chinese HWLs could be
compared to HWLs that the Chinese Government COULD HAVE
put on their packs:

– Canadian HWL on lung cancer—text + PICTURE

– Canadian HWL on lung cancer—text only
– Singapore HWL on mouth disease—text + PICTURE
– Singapore HWL on mouth disease—text only
– Hong Kong HWL on gangrene—text + PICTURE
– Hong Kong HWL on gangrene—text only
– European Union HWL on clogged arteries—text + PICTURE
– European Union HWL on clogged arteries—text only

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 Design

At the same time that the actual Chinese health warnings were
being compared to these 8 alternative warnings, the composition
of the 8 alternatives allowed us to explicitly test the hypothesis
that adding the picture would be beneficial. The 8 warnings
followed a 2 x 4 design:

Canadian Singapore Hong EU

Lung Mouth Kong Clogged
Cancer Disease Gangrene Arteries
Text only
Text + picture

This design allows the possibility of explicitly testing:

Whether adding picture to a text warning is beneficial
Whether the content domain (lung cancer vs. mouth disease...)
leads to greater perceived effectiveness
Whether there is an interaction between content domain and
adding a picture (e.g., did adding the photo to the lung cancer
warning increase its perceived effectiveness to a greater extent
than adding the photo to the gangrene warning?)
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 The full layout of the design: 2 x 4 + China
Canadian Singapore Hong Kong EU
Lung Mouth Gangrene Clogged and China
Cancer Disease Arteries

Text
Only
2 6 3 10 5

Text +
Picture

9 8 1 4 7

Numbers = randomized order of the warnings

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Rating Task: motivating smokers to quit

Rate each of the 10 labels on how effective each label would be in motivating smokers to quit

Extremely Very Somewhat A little bit Not at all

Effective Effective Effective Effective Effective
Label
#1
Label
#2
Label
#3
Label
#4
Label
#5
Label
#6
Label
#7
Label
#8
Label
#9
Label
#10

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Rating Task: convincing youth not to start

Rate each of the 10 labels on how effective each label would be in convincing youth
not to start smoking.

Extremely Very Somewhat A little bit Not at all

Effective Effective Effective Effective Effective
Label
#1
Label
#2
Label
#3
Label
#4
Label
#5
Label
#6
Label
#7
Label
#8
Label
#9
Label
#10
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Results

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 Ranking Task

 All participants also RANKED the 10 labels on

effectiveness on 4 dimensions:
– Motivating smokers to quit
– Convincing youth not to start smoking
– Informing the public about the harms of smoking
– Chinese Government is serious about reducing smoking

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Comparing rankings and ratings: nearly identical findings

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 Correlations Between Ratings and Rankings

 Average within-person correlation = +.73

 Aggregate correlation (bar charts) > +.99

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Ranking data show the enormous difference in effectiveness
between China and warnings from other countries

• Over 80% ranked

the China warning
as least effective or
2nd least effective

• 60% ranked the

Singapore picture
warning as most
effective or 2nd
most effective

Clear differences:
• China label is worst
• Singapore text is
much better
• Singapore picture is
best of all
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Summary of Findings from the Ratings & Rankings
 The two actual Chinese warnings were the lowest rated
and ranked of all 10 warnings
 The mean ratings and rankings of the new Chinese
warning (30% on front and back) are barely higher than
the old Chinese warning (side of pack)
 The new Chinese warnings are rated/ranked much lower
than each of the other text warnings from other countries.
 The new Chinese warnings are rated/ranked much much
lower than the warnings with pictures
 Picture warnings are superior to text warnings: All of the
picture warnings were rated/ranked higher than their
corresponding text warnings (and every one of the picture
warnings had a better rating/ranking than every other text
warnings)
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 Do these findings differ by...?

 Participant type: Adult Smokers, Adult Non-Smokers, Youth

 City: Beijing, Shanghai, Kunming, Yinchuan

 Participant gender

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Participant Type: Smokers, Non-Smokers, Youth

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Gender: Males and Females

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City: Beijing, Shanghai, Kunming, Yinchuan

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 Summary of Findings on Pictures vs. Text Only

 Picture warnings are superior to text warnings

All of the picture warnings were rated higher than their
corresponding text warnings (and every one of the picture
warnings had a higher rating than every one of the text warnings)

 Pictures vary in their strength (and so does text)

The Singapore mouth disease text warning was the lowest rated
of the four non-China text warnings. But when the picture was
added, it jumped to 2nd of the four non-China picture warnings.
One explanation is that the mouth photo was particularly dramatic
and thus led to a greater enhancement in the ratings. But it is also
possible that the text was particularly poor. So we can’t strictly tell
where the effect is. This could easily be assessed by adding
conditions in which the pictures were varied with same text and
text was varied with same pictures.
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Using English on the Warnings on the Back

 Each respondent was asked BEFORE the warning rating

and ranking tasks to translate two phrases in English (so
they were not prompted about the presence of these
phrases on cigarette packs):
1. “Smoking is harmful to your health.”
– The main warning—appears on ALL packs.
2. “Quit smoking early is good for your health.”
– This is the second line of the warning—appears on
half of the packs; rotated with a VERY similar phrase:
“Quitting smoking is good for your health
 What % of participants could understand the English text of
the Chinese warnings?
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% of Participants who correctly translated the two
English-language warnings by type of participant

Translation phrase Adult Adult Youth Total

Smoker Non-Smoker
“Smoking is
harmful to your 26.8% 51.5% 90.4% 56.3%
health.”
“Quit smoking
early is good for 10.1% 24.7% 47.7% 27.5%
your health.”

73% and 90% of adult smokers do not

understand the English warnings!

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% of Participants who correctly translated the two
English-language warnings by city

Translation
Beijing Kunming Shanghai Yinchuan Total
phrase
“Smoking is
harmful to your 58.8% 57.1% 50.3% 59.1% 56.3%
health.”
“Quit smoking
early is good for 37.9% 27.4% 18.0% 27.7% 27.5%
your health.”

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% of Participants who correctly translated the two
English-language warnings by gender

Translation
Males Females Total
phrase
“Smoking is
harmful to your 59.1% 53.4% 56.3%
health.”
“Quit smoking
early is good for 30.0% 25.1% 27.5%
your health.”

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 Conclusions
 Very strong evidence that the new Chinese warnings are much
lower in effectiveness than the warnings from other countries,
especially the picture warnings. Enormous gap between Chinese
warnings and the recommended picture warnings.
 The results are the same for adult smokers and non-smokers and
for youth, in all four cities, for males and females, whether
rankings or ratings are used. Results are remarkably consistent.
 The majority of participants could not understand the English
warnings on the back of the pack.
 Absolutely clear that the new Chinese warnings are ineffective
and that they should be revised to conform with the Article 11
guidelines. There are MANY examples of strong warnings from
other countries that could easily be used in China.
 Strong and effective warnings are absolutely essential for China
to educate the people on the harms of smoking: to motivate
smokers to quit and to convince youth not to start. 37
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