Cancer Control Program, Moores Cancer Center, University of California, San Diego, La Jolla.
Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego.
JAMA Netw Open. 2022 Jun 1;5(6):e2214242. doi: 10.1001/jamanetworkopen.2022.14242.
The inclusion of graphic warning labels (GWLs) on cigarette packs is recommended for tobacco control but has not yet been implemented in the US. It is unknown whether and to what extent the inclusion of GWLs on cigarette packs affects smokers' willingness to display the packs in public.
To determine whether the inclusion of GWLs on cigarette packs affects pack-hiding behavior among smokers in social settings.
DESIGN, SETTING, AND PARTICIPANTS: This community-based randomized clinical trial assessed smokers' real-world experience of using cigarettes repackaged to include GWLs (GWL packs) compared with standard US packs and blank packs over a 3-month intervention period with 12 months of follow-up between September 6, 2016, and December 3, 2019. The study included 357 participants aged 21 to 65 years from San Diego County, California, who smoked 5 or more cigarettes per day, were not actively planning to quit smoking, were not pregnant, and had no unstable medical conditions. Participants purchased and received cigarette packs through the study website.
During the 1-month run-in period, participants received their usual US cigarette packs. During the 3-month intervention period, participants were randomized to receive GWL packs (study-manufactured packs with 3 rotating images under license from the Commonwealth of Australia; GWL pack group), blank packs (study-manufactured packs devoid of industry marketing imagery; blank pack group), or standard US packs (US pack group).
Pack hiding was queried daily (with participants reporting behavior within the last 4 hours) and weekly via interactive text messages during the 1-month run-in and intervention periods. Self-reported smoking behavior was biochemically validated.
Among 357 enrolled participants, the mean (SD) age was 39.3 (11.8) years; 195 participants (54.6%) were female, 40 (11.2%) were Hispanic, 243 (68.1%) were non-Hispanic White, and 74 (20.7%) were of other non-Hispanic races (including American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, or multiracial). A total of 18 987 cigarette packs were purchased and delivered during the run-in and intervention periods. Daily querying showed that the inclusion of GWLs on cigarette packs increased the percentage of smokers who hid their packs at least some of the time from 41.3% (95% CI, 39.6%-43.0%) during the run-in period to 57.1% (95% CI, 55.9%-58.1%) by the end of the intervention period. In the postintervention period, returning to standard US packs reduced pack-hiding behavior to the levels observed during the run-in period. Pack hiding remained at run-in levels for both the blank pack group (35.2%; 95% CI, 33.6%-36.8%) and the US pack group (41.4%; 95% CI, 39.7%-43.1%]) throughout the study. Although even participants in the GWL group with the lowest prestudy tendency to conceal score (ie, 1) had a mean (SE) probability of pack hiding during the intervention of 0.84 (0.02), this group's probability of pack hiding decreased to a mean (SE) of 0.43 (0.03) after intervention. When social reactions to packs were queried at the end of the study, the modal response from participants in the GWL pack group was observers' aversive reactions to the packs, whereas the modal response from participants in the blank pack group was observers' positive interest in the study. Neither smoking prevalence nor consumption differed by group at any point in the study.
In this randomized clinical trial, receiving cigarettes in GWL packs vs blank packs increased pack-hiding behavior in social settings, which may be associated with aversive reactions from observers. However, 12-month smoking behavior did not change.
ClinicalTrials.gov Identifier: NCT02676193.
在烟草控制方面，建议在香烟包装上使用图形警示标签（GWL），但尚未在美国实施。目前尚不清楚在香烟包装上使用 GWL 是否以及在何种程度上影响吸烟者在公共场合展示烟盒的意愿。
确定在社会环境中，香烟包装上使用 GWL 是否会影响吸烟者隐藏烟盒的行为。
设计、地点和参与者：这项基于社区的随机临床试验评估了吸烟者在 3 个月的干预期内使用重新包装的 GWL 香烟包（GWL 包）与标准美国包和空白包相比的真实世界体验，随访期为 12 个月，从 2016 年 9 月 6 日至 2019 年 12 月 3 日。研究包括来自加利福尼亚州圣地亚哥县的 357 名年龄在 21 至 65 岁之间的参与者，他们每天吸烟 5 支或 5 支以上，不积极计划戒烟，不怀孕，且没有不稳定的医疗条件。参与者通过研究网站购买和接收香烟包。
在 1 个月的运行期内，参与者收到他们通常使用的美国香烟包。在 3 个月的干预期内，参与者被随机分配到 GWL 包组（由澳大利亚联邦授权许可的 3 个旋转图像研究制造的包；GWL 包组）、空白包组（研究制造的无行业营销图像的包；空白包组）或标准美国包组（美国包组）。
在 1 个月的运行期和干预期内，通过交互式短信每天（参与者报告过去 4 小时内的行为）和每周查询包装隐藏情况。自我报告的吸烟行为通过生物化学验证。
在 357 名入组参与者中，平均（SD）年龄为 39.3（11.8）岁；195 名参与者（54.6%）为女性，40 名（11.2%）为西班牙裔，243 名（68.1%）为非西班牙裔白人，74 名（20.7%）为其他非西班牙裔种族（包括美洲印第安人或阿拉斯加原住民、亚洲或太平洋岛民、非裔美国人或非洲裔美国人、或多种族）。在运行期和干预期内共购买和交付了 18987 个香烟包。每日查询显示，在运行期内，香烟包装上使用 GWL 增加了至少部分时间隐藏烟盒的吸烟者比例，从 41.3%（95%CI，39.6%-43.0%）增加到干预期末的 57.1%（95%CI，55.9%-58.1%）。在干预后期间，恢复使用标准美国包将包装隐藏行为降低到运行期观察到的水平。空白包组（35.2%；95%CI，33.6%-36.8%）和美国包组（41.4%；95%CI，39.7%-43.1%）的包装隐藏行为在整个研究期间都保持在运行期水平。尽管即使是在研究前隐藏倾向最低（即 1）的 GWL 组参与者在干预期间隐藏烟盒的平均（SE）概率为 0.84（0.02），但该组隐藏烟盒的概率在干预后降至 0.43（0.03）。当在研究结束时查询对烟盒的社会反应时，GWL 包组参与者的模态反应是观察者对烟盒的厌恶反应，而空白包组参与者的模态反应是观察者对研究的积极兴趣。在研究的任何阶段，吸烟率和吸烟量都没有因组而异。
在这项随机临床试验中，与空白包相比，收到 GWL 包的香烟增加了在社会环境中隐藏烟盒的行为，这可能与观察者的厌恶反应有关。然而，12 个月的吸烟行为并没有改变。
ClinicalTrials.gov 标识符：NCT02676193。
