Health behavior science and global public health: Transnational research

collaborations to address non-communicable diseases

James F. Thrasher, MA, MS, PhD

February 24, 2016 INSTITUTO NACIONAL DE SALUD PÚBLICA MÉXICO

Overview • Global burden of non-communicable disease

– Health Behavior Science

• Packaging as a vehicle for communication – Public health and industry strategies

• Direct & indirect marketing – Entertainment media & Internet

• New products – Flavor capsules & E-cigarettes

• Extensions to nutrition and obesity

Noncommunicable disease (NCD) mortality by country income, 2008-2030

Source: World Health Organization, Projections of Mortality and Burden of Disease, 2004-2030. Available at: http://www.who.int/healthinfo/global_burden_disease/projections/en/index.html.

Tobacco

Unhealthy diet

Physical inactivity

Alcohol

WHO-Targeted Risk Factors Cancers Diabetes

Chronic Respiratory

Diseases

Cardio-vascular disease

WHO NCD Action Plan Primary NCDs

World Health Organization: http://www.who.int/nmh/events/ncd_action_plan/en/

WHO’s Framework Convention on Tobacco Control (WHO-FCTC)

Tobacco control environment •Media campaigns

• PR activities •Tobacco control

• Taxes • Smoke-free • Ad bans

•Cessation services

Pro-tobacco environment •Advertising, promotions & sponsorship

• PR activities •Price •Product design •Social visibility

Size, shape & brand imagery

Health warning label Relative size & location

Execution & Design

Product environment Packaging & warning label characteristics for

tobacco and other product categories

Health warning labels (HWLs) in context

Cigarette package design

Pictorial content

Textual content

Warning wearout study

Longitudinal study sample - Online consumer panels – 1000 to 1400 adult smokers in each country every 4 months

•Fastest rotation

• Long exposure • Inserts

•Plain packaging

2012 2013 2014 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9

•Control

R01 CA167067 PI: Thrasher

Attention to HWLs* over time

Thrasher et al. Warning wearout. Preliminary results

*In the last month, how often: • have you noticed health warnings on cigarette packages? • have you read or looked closely at the warning labels?

Never; Rarely; Sometimes; Often; Very often

2nd HWLs Canada

2nd HWLs Australia

Interpersonal communication about HWLs, last month

Thrasher JF et al. Social Science & Medicine (2016)

2nd HWLs Canada

2nd HWLs Australia

Downstream quit attempts predicted by: • Talking about HWLs in last month • Family talked with you @ HWLs • Non-family talked with you @ HWLs • Making fun of HWLs

HWL responses & smoking cessation: Not moderated by reactance or self-efficacy

Reactance: Tendency to react negatively toward threats to restrict freedom of choice. Can cause adoption or strengthening of attitude that is contrary to what was intended, increasing resistance to persuasion.

Higher trait reactance of lower Self-efficacy slightly weaker or same HWL responses (unassociated with cessation)

Higher state reactance stronger HWL responses (greater cessation attempts) BUT no moderation

Thrasher JF et al. Health Communication (In press)

Graphic HWLs rated as more

effective, especially

among low-literacy smokers

Suffering

Symbolic

Graphic

Thrasher JF, et al Cancer Causes and Control. 23:69–80. 2012

Hammond D, et al. Cancer Causes and Control. 23:69–80. 2012.

Thrasher JF et al. American Journal of Preventive Medicine. 43:590–600. 2012.

Thrasher JF. Salud Pública de México. 52: S206-215. 2010.

Assessing warning imagery: fMRI

Newman-Norland R, Thrasher JF, et al. BMJ Open. Dec 31;4(12):e006411. 2014.

Graphic- Rest

Suffering - Rest

Symbolic - Rest

Inserts: Positively framed messages &

tips for quitting

Thrasher JF et al. Nicotine & Tobacco Research. 17(7): 870-875. 2015.

Frequency of reading inserts in the last month & future quit attempts

More likely to read inserts if: • Younger • Intend to quit • Recently tried to quit • Stronger negative outcome expectancies

Frequency of reading inserts OR AOR* Not at all 1 1 Once 1.46 1.17 A few times 1.95c 1.70a Often / very often 2.20b 2.26a

*Adjusted for baseline age, sex, education, income, HSI, quit intention, recent quit attempt, self-efficacy to quit, risk perceptions, time in sample

Dow

nstr

eam

att

empt

to q

uit

a: p<0.05; b: p<0.01: c: p<0.001

Freq in last mo.

Thrasher JF et al. Nicotine & Tobacco Research. 17(7): 870-875. 2015

Inserts with harmful

constituent information

Australia

Canada

Coupons Trading cards

“Silks”

> 100 years of tobacco “inserts”

Create synergies beteween HWLs, media campaigns & cessation resources

Thrasher JF et al. Linking media campaigns to pictorial warning labels on cigarette packages. Tobacco Control. 2013. Thrasher JF et al. Towards informed tobacco consumption in Mexico. Mexican Journal of Public Health. 2012. Thrasher JF et al. Promoting cessation resources through cigarette package warning labels. Tobacco Control. 24(e1):e23-31. 2015. Nagelhout et al. Was the media campaign that supported Australia's new pictorial cigarette warning labels and plain packaging policy

associated with more attention to and talking about warning labels? Addictive Behavior. 49:64-7. 2015

LIBRE DE TABACO

Adult smokers’ responses to

plain packaging in Australia

Implementation of plain packaging associated with: More awareness of harms from smoking More attention toward and use of cessation resource information (quitline & website) on HWLs More discussion & cessation-related responses to HWLs Increased support for plain packaging (28% vs 49%)

Before After

Thrasher JF et al, Promoting cessation resources through cigarette package warning labels. Tobacco Control. 24(e1):e23-31. 2015 Swayampakala et al. Pictorial health warning label content & smokers’ understanding of smoking-related risks. HER 30(1):35-45. 2015. Thrasher JF et al. Interpersonal communication about pictorial health warnings on cigarette packages. Social Science & Medicine. 2016. Swift E et al. Australian smokers’ support for plain packaging before and after implementation.. Tobacco Control (in press)

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Perc

enta

ge

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

19 Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Perc

enta

ge

CanadaAustraliaUSUK

$3.52 $3.43$3.11 $2.93

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

Control Text Pictorial PlainThrasher JF et al. Health Policy. 102: 41–48. 2011. Rousu M, Thrasher JF. Health Education Research. 29(2):183-94. 2014.

Auction experiment among US smokers: 17% difference in demand

1 – Branded (n=214)

3 – Plain, no descriptors

(n=218)

2 – Plain (n=208)

Source: White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health. 12(1):737. 2012.

Sample: • 640 females; 16 to 26 years old (mean=22); 28% smokers

Perceived Health Risk

“A little” or “A lot” less harmful than other brands

24% 11% 18%

(p<0.001 for ‘branded vs. plain, no descriptors’)

Source: White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health. 12(1):737. 2012.

Preference for cigarette brand variety with flavor capsule in US, Mexico &

Australia, 2012-2014

Weighted and adjusted predicted probabilities Thrasher JF et al, Tobacco Control. 2015.

Data source: Euromonitor, 2008 - 2014

Market share for flavor capsules cigarettes, 2008-2014 Latin

American Countries

Product innovations: flavor capsule cigarettes

• Flavor capsule packaging perceived as the most attractive • Greater trial (smokers) & willingness to try (never smokers)

Abad-Vivero E et al. (under review)

IOM Guiding Stars

Facts Up Front

Front of package nutrition labeling systems

Product presentation: Cereal

Blake C, Rosemond T, Kim J, Thrasher JF. (under review)

Countries where studies indicate that exposure to tobacco imagery in films promotes youth smoking

Countries • Germany • Holand • Hong Kong • Iceland • India • Italy • Mexico • Norway • New Zealand • Poland • Scotland • Thailand • United Kingdom • USA

Percentage of US-produced films with tobacco by US rating, 2004 - 2012

All films

How adult-rated US films (“R”) get rated in Argentina, Brazil, and Mexico, 2002-2009

Argentina Brazil México

Thrasher JF et al. Are movies with tobacco, alcohol, drugs, sex, and violence rated for youth?: A comparison of Argentina, Brazil, Mexico, and the United States. International Journal of Drug Policy. 2014.

64% 49%

27%

73%

Tobacco & tobacco brands in Mexican-, Argentine- & US-produced films, 2004-2012

Films with tobacco & tobacco brands, by country of production, 2004-2012

Barrientos et al. BMC Public Health. 2015. Mejía R et al. Under review.

Films with tobacco by country of production, 2004-2012

WHO recommended policies • Prohibit brand imagery • No subsidies for films

with tobacco imagery • Films with tobacco:

– Adult rating

– Anti-smoking ad

– Certification of no payment from the tobacco industry

Percent of videogames with tobacco rated for ages 13 and older, 1994-2011

Barrientos-Gutierrez T, Barrientos-Gutierrez I, Lazcano-Ponce E, Thrasher JF. Tobacco content in video games: 1994-2011. Lancet Oncology. 2012.

Barrientos-Gutierrez T, Barrientos-Gutierrez I, Thrasher JF. Videogames and the next tobacco frontier: Smoking in the Starcraft Universe. Tobacco Control. 2012

Any tobacco content

Starcraft

Trial of e-cigarettes and conventional cigarettes amongst secondary school youth in Mexico, 2015

• E-cig trial almost as high as for adult smokers

• E-cig trial independently associated with traditional cigarette risk factors.

• Novel risk factors, including risk for e-cig only vs cigarette only: • Use of media technologies • Internet advertising

exposure

Thrasher JF et al. Journal of Adolescent Health. 2016.

n=10,068

Thanks! Jim Thrasher

thrasher@sc.edu

Funding:

Collaborating Institutions:

INSTITUTO NACIONAL DE SALUD PÚBLICA MEXICO