Avoidance of tobacco health warnings? An eye-tracking approach

Aims: Across three eye-tracking studies, we examined how the location, framing, immediacy, and severity of health warnings on branded cigarette packs affected visual attention and self-reported avoidance of and reactance to warnings. Design: Study 1: smoking status × warning immediacy (short-term vs. long-term) × warning location (top of back vs. bottom of pack). Study 2: smoking status × warning framing (gain-framed vs. loss-framed) × warning format (text-only vs. pictorial). Study 3: smoking status × warning severity (highly-severe vs. moderately-severe). Setting: University of Bristol, UK, eye-tracking laboratory. Participants Study 1: non-smokers (n=25), weekly smokers (n=25), and daily smokers (n=25). Study 2: non-smokers (n=37), smokers contemplating quitting (n=37) and smokers not contemplating quitting (n=43). Study 3: non-smokers (n=27), weekly smokers (n=26) and daily smokers (n=26). Measurements: For all studies: relative number of fixations to the warning vs. the brand, self-reported avoidance of and reactance to warnings and for Study 3: effect of warning on quitting motivation. Findings: Study 1: Greater self-reported avoidance (p<0.001) and greater visual attention (p=0.03) to long-term warnings, but no difference for reactance (p=0.12). Increased visual attention to warnings on the upper- versus lower-half of the pack (p=0.02). Study 2: Higher self-reported avoidance of (p<0.001) and reactance to (p<0.001) loss-framed warnings but little evidence of a difference for visual attention (p=0.30). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all ps>0.001). Study 3: Greater self-reported avoidance of (p<0.001) and reactance (p=0.003) to highly-severe warnings but no clear difference in visual attention (p=0.24). Conclusions: Subjective (self-report) and objective (eye-tracking) measures of warning avoidance produced different outcomes, suggesting these capture different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported avoidance reflects higher-level cognitive awareness and engagement with warnings. We suggest that loss-framed, long-term, highly-severe images are likely to be most effective in communicating harm.