Date of Degree

9-2015

Document Type

Dissertation

Degree Name

D.P.H.

Program

Public Health

Advisor

William T. Gallo

Subject Categories

Public Policy

Keywords

Graphic cigarette warnings; Smoking; Southeast Asia; Tobacco policy; Tobacco use

Abstract

The objective of this dissertation was to investigate the impact of graphic cigarette warning label policies enacted in Thailand and Malaysia on youth and adult smoking outcomes. We sought to examine the effect of the policy on youth smoking intention, susceptibility, and behaviors. Among adults, who were all baseline smokers, we sought to examine the effects of graphic warning labels on smoking intensity, quit attempts, and cessation. Secondary data were utilized from the International Tobacco Control (ITC) South East Asia (SEA) Survey, a nationally representative cohort survey for which eight years of data spanning from 2005 to 2012 were available. Multiple wave-pairs of data were analyzed concurrently using generalized estimating equations (GEEs) with the predictors measured at a baseline wave (wave t) predicting outcomes measured at the next wave, the outcome wave (wave t + 1). Thus, it was possible for participants to provide data for multiple wave-pairs which increased the power of the study.

We analyzed our data using two approaches. In our first approach, we utilized a quasi-experimental design capturing the time period after which Thailand had enacted the policy, but prior to policy implementation in Malaysia. Using this approach, outcomes were assessed for our Thai sample using the Malaysian sample as a control, whereby country differences reflected the effects of the graphic warning label policy. In our second approach, we limited the data to the post-policy implementation period in both countries to assess the effect of frequency of exposure to graphic warning labels on smoking outcomes among youth and adults. We employed measures of risk cognition and label salience as proxies for frequency of exposure, due to the potential collinearity between smoking status and exposure to warning labels which may have contaminated our analyses of smoking outcomes.

This study found that graphic cigarette warning labels significantly reduced future smoking intention among Thai male youth smokers, as well as increased the odds of intending to quit smoking within 6 months. Among female never-smokers, the policy decreased intention to smoke. We also found high cognition of risk to be significantly associated with decreased susceptibility to smoking, decreased odds of smoking initiation, and reduced smoking intensity among male youth.

Among adult smokers, our findings indicate that any label salience was associated with increased odds of attributing quit status to warning labels among male smokers in Thailand and all adult smokers in Thailand (versus no salience). High label salience was associated with increased odds of making a quit attempt among male smokers in Thailand, all smokers in Thailand, and male smokers in Thailand and Malaysia (versus low salience); and increased odds of attributing quit status to warning labels among male smokers in Thailand and all adult smokers in Thailand (versus low salience). A secondary goal of our research was to explore purchasing loose cigarettes, or loosies, as an effect modifier of the association between label salience and smoking outcomes. The investigation of loosies is imperative, as some researchers have raised concerns that smokers will employ avoidance tactics such as covering cigarette packs or purchasing loosies to avoid graphic labels. Our findings indicate that loosies are actually associated with positive smoking outcomes: among smokers reporting any label salience, we found reduced odds of high intensity smoking among smokers in Thailand and Malaysia who purchased loosies (versus those who did not purchase loosies). Among respondents who reported high salience, we found reduced odds of high intensity smoking among smokers in Thailand and Malaysia who purchased loosies (versus those who did not purchase loosies).

In conclusion, the findings of this study support the effectiveness of graphic cigarette warning labels in reducing intention to smoke and smoking behaviors among youth and adults in Southeast Asia. If current trends persist, tobacco will kill more than 8 million people worldwide annually by the year 2030, with 80 percent of these deaths in low- and middle-income countries. It is imperative that we continue to support the implementation of cost-effective public health policies to reverse these trends and reduce smoking-related morbidity and mortality.

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