Search

Background: Health warning labels (HWLs) on cigarette packs in Australia, Canada, Mexico, and the United States include varying information about toxic cigarette smoke constituents and smoking-related health risks. HWL information changed more recently in Australia, Canada, and Mexico than in the United States. Aims: To investigate whether smokers' knowledge of toxic constituents and perceived smoking-related risks increased after adding this information to HWLs and how knowledge of toxic constituents is associated with perceptions of smoking-related risks. Methods: Data come from a longitudinal, online cohort of 4,621 adult smokers surveyed every 4 months from September 2012 (Wave 1) to January 2014 (Wave 5) in Australia, Canada, and Mexico, with the United States being surveyed from Waves 2 to 5. Generalized estimating equation models estimated the association between perceived smoking-related risk at follow-up and prior wave knowledge of toxic constituents, adjusting for attention to HWLs, sociodemographics, and smoking-related characteristics. Results: Between 2012 and 2014, knowledge of toxic constituents increased in Australia, Canada, and Mexico (p < 0.001), but not in the United States. Higher levels of both attention to HWLs and knowledge of toxic constituents were associated with a higher perceived risk of smoking-related conditions at follow-up across all countries except for the United States. Conclusions: Our results suggest that information about toxic constituents on prominent HWLs not only increases smoker's knowledge of toxic constituents, but that it may also reinforce the effects of HWL messages about specific, smoking-related health outcomes.

Background: Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages. Methods: Data came from 14 to 17 year old youth (n = 1,696) and adults ≥ 18 (n = 7,775) who participated in the Mexican arm of the 2020–2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of nine unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well. Results: Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs. Conclusion: Our findings suggest that implementation of WLs has reduced perceived purchases of unhealthy foods in Mexico. These results underscore the potential positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults. [ABSTRACT FROM AUTHOR]

Health warning labels (HWLs) on cigarette packs that use strong fear appeals may evoke defensive responses including acts of disparaging the warnings. Whether warning disparagement undermines HWL effectiveness remains unclear. We assessed correlates of one type of HWL disparagement and its association with subsequent cessation attempts. Longitudinal data (2012-14) on adult smokers from Australia, Canada, Mexico and the United States (US) were analyzed. HWL disparagement was assessed as the frequency of making fun of HWLs in the past month. Using Generalized Estimating Equation models we estimated correlates of HWL disparagement and whether HWL disparagement predicted subsequent cessation attempts. In each country, across all waves, 24-31% of smokers reported making fun of the warnings at least once in the past month. More frequent disparagement was found among males, younger participants, those with higher education and greater addiction, and those who recently attempted to quit. Attention to, avoidance of and talking to others about HWLs were all positively associated with HWL disparagement. In all countries, except the US, this type of HWL disparagement was an independent predictor of subsequent cessation attempts. HWL disparagement among smokers may indicate greater warning relevance and processing and does not result in counterproductive effects on cessation efforts.

The aim of the present study was to assess smokers' level of agreement with smoking-related risks and toxic tobacco constituents relative to inclusion of these topics on health warning labels (HWLs). 1000 adult smokers were interviewed between 2012 and 2013 from online consumer panels of adult smokers from each of the three countries: Australia (AU), Canada (CA) and Mexico (MX). Generalized estimating equation models were estimated to compare agreement with smoking-related risks and toxic tobacco constituents. For disease outcomes described on HWLs across all three countries, there were few statistical differences in agreement with health outcomes (e.g. emphysema and heart attack). By contrast, increases in agreement where the HWLs were revised or introduced on HWLs for the first time (e.g. blindness in AU and CA, bladder cancer in CA). Similarly, samples from countries that have specific health content or toxic constituents on HWLs showed higher agreement for that particular disease or toxin than countries without (e.g. higher agreement for gangrene and blindness in AU, higher agreement for bladder cancer and all toxic constituents except nitrosamines and radioactive polonium in CA). Pictorial HWL content is associated with greater awareness of smoking-related risks and toxic tobacco constituents.

Objective: Front-of-package warning labels introduced in Mexico in 2020 included disclaimers that caution against allowing children to consume products with non-sugary sweeteners and caffeine. We examined the awareness and use of the disclaimers among Mexican adults and youth 1 month after the regulation was implemented. We also investigated their impact on the perceived healthfulness of industrialised beverages designed for children. Design: Data on the awareness and use of the disclaimers were analysed. Two between-subjects experiments examined the effect of a sweetener disclaimer (Experiment 1, youth and adults) or a caffeine disclaimer (Experiment 2, only adults) on the perceived healthfulness of industrialised beverages. Interactions between experimental conditions and demographic characteristics were tested. Setting: Online survey in 2020. Participants: Mexican adults (≥18 years, n 2108) and youth (10–17 years, n 1790). Results: Most participants (>80 %) had seen the disclaimers at least rarely, and over 60 % used them sometimes or frequently. The sweetener disclaimer led to a lower perceived healthfulness of a fruit drink (adults: 2·74 ± 1·44; youth: 2·04 ± 0·96) compared with the no-disclaimer condition (adults: 3·17 ± 1·54; youth: 2·32 ± 0·96) (t 's: >4·0, P values: <0·001). This effect was larger among older adults and male youth. The caffeine disclaimer did not affect adult's perceived healthfulness of a caffeinated drink (t = 0·861, P value = 0·3894). Conclusions: There were high awareness and use of the sweeteners and caffeine disclaimers shortly after the warning labels were implemented. The sweetener disclaimer appears to be helping consumers modify their perceptions regarding industrialised beverages for children. Findings may help decision-makers improve the regulation and better target communication strategies. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups. Design: Cross-sectional data from the International Food Policy Study (IFPS) online survey. Setting: IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019. Participants: Adults aged 18–99; n 19 393. Results: Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy. Conclusions: Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small. [ABSTRACT FROM AUTHOR]

Background: Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy. Methods: A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs. Results: Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p <.001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p <.001 for all). Conclusions: Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to identify correlates of nutrition label awareness and use, particularly subgroup differences among consumers. Two label types were assessed: (1) nutrition facts tables (NFt) in Australia, Canada, Mexico, UK, and USA and (2) front-of-package (FOP) labels, including mandatory Guideline Daily Amounts (Mexico), voluntary Health Star Ratings (Australia) and voluntary Traffic Lights (UK).Design: Respondents were recruited using Nielsen Consumer Insights Global Panel (n 21 586) and completed online surveys in November-December 2018. Linear regression and generalised linear mixed models examined differences in label use and awareness between countries and label type based on sociodemographic, knowledge-related and dietary characteristics.Setting: Australia, Canada, Mexico, UK and USA.Participants: Adults (≥18 years).Results: Respondents from the USA, Canada and Australia reported significantly higher NFt use and awareness than those in Mexico and the UK. Mexican respondents reported the highest level of FOP label awareness, whereas UK respondents reported the highest FOP label use. NFt use was higher among females, 'minority' ethnic groups, those with higher nutrition knowledge and respondents with 'adequate literacy' compared with those with 'high likelihood of limited literacy'. FOP label use was higher among those with a 'high likelihood of limited literacy' compared with 'adequate literacy' across countries.Conclusions: Lower use of mandatory Guideline Daily Amount labels compared with voluntary FOP labelling systems provides support for Mexico's decision to switch to mandatory 'high-in' warning symbols. The patterns of consumer label use and awareness across sociodemographic and knowledge-related characteristics suggest that simple FOP labels may encourage broader use across countries. [ABSTRACT FROM AUTHOR]

Background: The public health benefits of sugar-sweetened beverage (SSB) taxes often rely on, among other things, changes to consumer purchases. Thus, perceived cost of SSBs and signalling effects—via awareness of the tax—may impact the effectiveness of SSB taxes on consumer purchases. Objective: The study sought to examine perceived cost of SSBs, tax awareness, and changes in beverage purchasing over time and across four countries with and without SSB taxes. Methods: The study used data from the 2017, 2018 and 2019 waves of the International Food Policy Study. Annual cross-sectional online surveys were conducted in Australia, Mexico, UK and US, which captured perceived cost of SSBs relative to non-SSBs in all countries (with Australia as a no-tax comparator), and measures of tax awareness and participants' reported changes in beverage purchasing in response to SSB taxes in Mexico (tax implemented in 2014), UK (tax implemented in 2018) and US (subnational taxes since 2015). Logistic regression models evaluated the measures across years and socio-demographic groups. Results: Perceived cost of SSBs relative to non-SSBs was higher in Mexico (all three years) and the UK (2018 and 2019 following tax implementation) than Australia and the US. Tax awareness was higher in UK than Mexico, and decreased over time among Mexican respondents. Patterns of reported beverage purchasing changes in response to the tax were similar across Mexico, UK and US, with the largest changes reported by Mexican respondents. Respondents with characteristics corresponding to lower socioeconomic status were less likely to be aware of an SSB tax, but more likely to perceive SSBs to cost more than non-SSBs and report changes in purchasing in response to the tax, where there was one. Conclusions: This study suggests that in countries where a national SSB tax was present (Mexico, UK), perceived cost of SSBs and tax awareness were higher compared to countries with no SSB tax (Australia) or subnational SSB taxes (US), respectively, and suggests that perceived cost and tax awareness represent distinct constructs. Improving the 'signalling effect' of existing SSB taxes may be warranted, particularly in tax settings where consumer behaviour change is a policy objective. [ABSTRACT FROM AUTHOR]

We explored socioeconomic gradients in self‐rated overall health (SROH) using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial perspectives (subjective social status (SSS)) among adults living in countries with varying levels of income inequality, and the importance of psychosocial stress in mediating these associations. If psychosocial processes at the individual and societal levels correspond, associations between SSS and SROH should be higher among adults in countries with higher income inequality, and psychosocial stress should be a more important mediator of these associations. We used multigroup structural equation models to analyse cross‐sectional data from the International Food Policy Study of adults (n = 22,824) in Australia, Canada, Mexico, the UK and the United States. Associations between SSS and SROH were not higher in more unequal countries, nor was psychosocial stress a more important mediator of these associations. Inequities in SROH in more unequal countries may not predominantly reflect stress‐related pathways of social status differentiation. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence and correlates of weight gain attempts in a pooled sample of adults aged 18 and older from Canada, Australia, the United Kingdom, the United States, and Mexico. Method: Data collected during 2 years (2018 and 2019) of the International Food Policy Study (N = 42,108) were analyzed. Unadjusted 12‐month prevalence of weight gain attempts was estimated based on body mass index (BMI; kg/m2), weight perception, country, survey year, and sex. Logistic regression analyses were estimated to determine the sociodemographic correlates (age, race/ethnicity, education, BMI, weight perception, weight perception accuracy, and self‐rated mental health) of weight gain attempts among the pooled sample stratified by sex. Results: Men (10.4%) were significantly more likely than women (5.4%) to report weight gain attempts (p <.001). Nearly one in five (17.1%) men with a BMI in the "normal" range (≥18.5 to <25.0) reported weight gain attempts. Among both men and women, minority group identity was associated with higher odds, while older age and higher BMI category were associated with lower odds, of reporting weight gain attempts. Country differences over the two survey years showed the prevalence of weight gain attempts in 2019 (vs. 2018) was higher among women in Australia (p <.05) and men in the United States (p <.01). Discussion: Weight gain attempts are more common among men, compared to women, across five countries, potentially reflecting the global salience of the pursuit of a muscular body. [ABSTRACT FROM AUTHOR]

Background: Food retail environments have an influential role in shaping purchasing behavior and could contribute to improving dietary patterns at a population level. However, little is known about the level of public support for different types of initiatives to encourage healthy food choices in supermarkets, and whether this varies across countries or context. The current study aimed to explore the level of support for three potential supermarket initiatives focused on product placement across five countries, and factors that may influence this support. Methods: A total of 22,264 adults from Australia, Canada, Mexico, the United Kingdom and the United States (US) provided information on support for three supermarket initiatives related to product placement (targeting product positioning: 'checkouts with only healthy products', 'fewer end-of-aisle displays containing unhealthy foods or soft drinks' or availability: 'more shelf space for fresh and healthier foods') as part of the online 2018 International Food Policy Study. The proportion of respondents that supported each initiative was assessed across countries, and multivariable logistic regression analyses were conducted to evaluate the influence of sociodemographic factors on support. Results: The initiative that received the highest support was 'more shelf space for fresh and healthier foods': 72.0% [95% CI 71.3–72.7], whereas 'checkouts with only healthy products' received the lowest support: 48.6% [95% CI 47.8–49.4]. The level of support differed between countries (p < 0.001 for all initiatives), with the US generally showing the lowest support and Mexico the highest. Noteworthy, in the overall sample, there was not much opposition to any of the initiatives (2.5–14.2%), whereas there was a large proportion of neutral responses (25.5–37.2%). Respondents who were older, female, highly educated, and those who reported having more nutrition knowledge tended to be more supportive, with several differences between countries and initiatives. Conclusions: Most people in the assessed five countries showed a generally high level of support for three placement initiatives in supermarkets to encourage healthy food choices. Support varied by type of initiative (i.e., product positioning or availability) and was influenced by several factors related to country context and sociodemographic characteristics. This evidence could prompt and guide retailers and policy makers to take stronger action to promote healthy food choices in stores. [ABSTRACT FROM AUTHOR]

Background: Despite considerable public health interest in sugary drink consumption, there has been little comparison of intake across countries.Objectives: This study aimed to compare the consumption frequency and amounts of commonly consumed beverages among adults in 5 upper-middle- and high-income countries, and examine differences in consumption between population subgroups.Methods: Adults aged 18-65 y completed online surveys in December 2017 in Australia (n = 3264), Canada (n = 2745), Mexico (n = 3152), the United Kingdom (n = 3221), and the USA (n = 4015) as part of the International Food Policy Study. The frequency of consuming beverages from 22 categories in the past 7 d was estimated using the Beverage Frequency Questionnaire. Regression models were used to examine differences in the likelihood of any consumption and in the amounts consumed of sugar-sweetened beverages (SSBs), sugary drinks (SSBs and 100% juice), diet, and alcoholic beverages between countries and across sociodemographic subgroups.Results: The prevalence of reported SSB consumption in the past 7 d ranged from 47% (United Kingdom) to 81% (Mexico), and that of sugary drinks ranged from 62% (United Kingdom) to 87% (Mexico). Rates of consumption of diet drinks ranged from 26% (Mexico) to 37% (United Kingdom), whereas alcoholic drink consumption rates ranged from 45% (USA) to 52% (Canada). Respondents in Mexico were more likely to consume SSBs and sugary drinks, and in greater amounts, than those in other countries. Respondents in the United Kingdom were more likely to consume diet drinks than those in Australia, Canada, and Mexico, and greater amounts of diet drinks were consumed in the United Kingdom and the USA. Across countries, younger respondents and males were more likely to consume greater amounts of SSBs and sugary drinks.Conclusions: Most adult respondents across all countries consumed SSBs and sugary drinks, with greater consumption in Mexico and the USA. Consumption varied greatly across countries, but patterns of association among subpopulations were relatively similar. [ABSTRACT FROM AUTHOR]

Background: Cartoon characters on processed food packaging increase the perception of product preference among children, but their effect among adults has rarely been examined. We evaluated the effect of a cartoon character on breakfast cereals on beliefs about buying them for children, as well as whether demographic characteristics modified this effect.Methods: An experimental study was conducted with adults from online consumer panels in Mexico (n = 3755). Participants were randomly assigned to a "cartoon" condition (n = 1789), in which they viewed a breakfast cereal box with a Minion character on the front of the package, or the "control" condition (n = 1966), in which the same cereal box was displayed with no character on the package. Participants were asked: "Is this a good cereal to buy children?" with the response options "Yes", "No", or "Don't know". Multinomial adjusted logistic models regressed responses to this question (Yes = 0, No = 1, 2 = Don't know) on experimental condition. Differences in the effect of the cartoon character across demographic characteristics were tested by introducing multiplicative interaction terms.Results: The adjusted model showed that participants in the "cartoon character" condition were 1.67 (1.45-1.94) times more likely to consider the cereal as being "Not good to buy for children" than those in the control condition (p < 0.001). This effect was smaller among parents (RRR = 1.39, 1.13-1.72) compared to those without children (RRR = 2.01, 1.63-2.47). No differences were observed in the proportion of participants answering "Don't know" across experimental groups.Conclusion: Among this sample of Mexican adults, a cereal with a cartoon character on the packaging was more often perceived as "not good to buy for children" compared to a cereal without it. This effect was smaller among parents, potentially due to children influences of parental decisions during food purchasing. [ABSTRACT FROM AUTHOR]

Latin Americans engage in physical activity (PA) in unique ways and use a wider range of places for PA than those commonly studied in high-income settings. We examined the contribution of a variety of places and domains of PA to meeting PA recommendations among a sample of adults (18–65 y) from all over Mexico. This was a cross-sectional study conducted in 2017 (n = 3 686). Overall and domain-specific PA was measured using the Global Physical Activity Questionnaire. Use of places for PA was self-reported. Places were classified as private or public. In 2018, associations between specific places and meeting PA recommendations (≥150 mins/week) were estimated using multivariate logistic regression models. In total 72.1% met PA recommendations. The proportion meeting recommendations through domain-specific PA was highest for leisure-time PA (50.0%), followed by travel-related (39.1%) and work-related (24.9%) PA. The most commonly reported places for PA were home (43%), parks (40.7%) and streets (39.4%) (public). Use of most public places was positively associated with meeting PA recommendations, mainly through travel-related PA (Streets OR 2.05 [95% CI 1.71–2.45]; Cycling paths OR 1.91 [1.37–2.68]). Using private places was more strongly associated with PA, mainly leisure-time PA (Gyms OR 9.66 [7.34–12.70]); Sports facilities OR 5.03 [3.27–7.74]). In conclusion, public and private places were important contributors to PA. While public places may be a powerful setting for PA promotion, increasing the equitable access for all to private places may also represent an effective strategy to increase PA among Mexican adults. [ABSTRACT FROM AUTHOR]

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing. Design, Setting, Participants and Measurements: A cross‐sectional analysis of adult (≥ 18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013–17. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs), not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs), not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand; (3) less restrictive policies (LRPs), legal to be sold and marketed with regulations: England, the Netherlands, Republic of Korea, United States; and (4) no regulatory policies (NRPs), Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily versus non‐daily). Findings NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries (ever‐use = 7.1–48.9%; current use = 0.3–3.5%) relative to LRP countries (ever‐use = 38.9–66.6%; current use = 5.5–17.2%) and RP countries (ever‐use = 10.0–62.4%; current use = 1.4–15.5%). NVP use was highest among high‐income countries, followed by upper–middle‐income countries, and then by lower–middle‐income countries. Conclusions: With a few exceptions, awareness and use of nicotine vaping products varied by the strength of national regulations governing nicotine vaping product sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in nicotine vaping products in these countries where smoking populations are predominantly poorer. The higher awareness and use of nicotine vaping products in high income countries with moderately (e.g. Canada, New Zealand) and less (e.g. England, United States) restrictive policies, is likely due to the greater availability and affordability of nicotine vaping products. [ABSTRACT FROM AUTHOR]

Plain cigarette packaging, which seeks to remove all brand imagery and standardize the shape and size of cigarette packs, represents a novel policy measure to reduce the appeal of cigarettes. Plain packaging has been studied primarily in high-income countries like Australia and the UK. It is unknown whether the effects of plain packaging may differ in low-and-middle income countries with a shorter history of tobacco regulation, such as Mexico. An experimental study was conducted in Mexico City to examine perceptions of branded and plain cigarette packaging among smoking and non-smoking Mexican adolescents (n = 359). Respondents were randomly assigned to a branded or plain pack condition and rated 12 cigarette packages for appeal, taste, harmto health and smoker-image traits. As a behavioral measure of appeal, respondents were offered (although not given) four cigarette packs (either branded or plain) and asked to select one to keep. The findings indicated that branded packs were perceived to be more appealing (β = 3.40, p < 0.001) and to contain better tasting cigarettes (β = 3.53, p < 0.001), but were not perceived as less harmful than plain packs. Participants rated people who smoke the branded packs as having relatively more positive smoker-image traits overall (β = 2.10, p < 0.001), with particularly strong differences found among non-smokers for the traits 'glamorous', 'stylish', 'popular' and 'sophisticated' (p < 0.001). No statistically significant difference was found for the proportion of youth that accepted when offered branded compared with plain packs. These results suggest that plain packaging may reduce brand appeal among Mexican youth, consistent with findings in high-income countries. [ABSTRACT FROM AUTHOR]

Objective To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters. Methods Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18-64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm. Results Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18-24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties. Conclusions Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action. [ABSTRACT FROM AUTHOR]

Introduction Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood. Methods Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs. Results At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia. Conclusions HWLs are an important source of cessation information. [ABSTRACT FROM AUTHOR]

Background: Obesity and chronic diseases could be prevented through improved diet. Most governments require at least one type of food labeling system on packaged foods to communicate nutrition information and promote healthy eating. This study evaluated adult consumer understanding and use of nutrition labeling systems in the US and Mexico, the most obese countries in the world. Methods: Adults from online consumer panels in the US (Whites n = 2959; Latinos n = 667) and in Mexico (n = 3533) were shown five food labeling systems: 1. Nutrition Facts Table (NFT) that shows nutrients of concern per serving; 2. Guideline Daily Amounts (GDA) that shows levels of nutrients of concern; 3. Multiple Traffic-Light (MTL) that color codes each GDA nutrient (green = healthy; yellow = moderately unhealthy; red = unhealthy); 4. Health Star Rating System (HSR) that rates foods on a single dimension of healthiness; 5. Warning Label (WL) with a stop sign for nutrients present in unhealthy levels. Participants rated each label on understanding ("easy"/"very easy to understand" vs "difficult"/"very difficult to understand"), and, for NFTs and GDAs, frequency of use ("sometimes"/"often" vs "never"). Mixed logistic models regressed understanding and frequency of use on indicators of labeling systems (NFT = ref), testing for interactions by ethnicity (US Latinos, US Whites, Mexicans), while controlling for sociodemographic and obesity-related factors. Results: Compared to the NFT, participants reported greater understanding of the WL (OR = 4.8; 95% CI = 4.4–5.3) and lower understanding of the HSR (OR = 0.34, 95% CI = 0.31–0.37) and the MTL (OR = 0.56, 95% CI = 0.52–0.61), with similar patterns across ethnic subgroups. Participants used GDAs less often than NFTs (OR = 0.48; 95%CI = 0.41–0.55), with the greatest difference among US Whites (OR = 0.10; 95%CI = 0.07–0.14). Conclusions: Understanding and use of the GDA was similar to that of the NFT. Whites, Latinos, and Mexicans consistently reported the best understanding for WLs, a FOPL that highlights unhealthfulness of a product. Therefore, a FOPL summary indicator, such as WLs, may be more effective in both the US and Mexico for guiding consumers towards informed food choices. [ABSTRACT FROM AUTHOR]

In 2020, Mexico implemented innovative front-of-package nutrition warning labels (FoPWLs) for packaged foods to increase the salience and understanding of nutrition information. This study evaluated Mexican Americans' self-reported exposure to Mexican FoPWLs and self-reported effects of FoPWLs on purchasing behavior. The 2021 International Food Policy Study surveyed online panels of adult Mexican Americans in the US (n = 3361) to self-report on buying food at Mexican-oriented stores, noticing Mexican FoPWLs, and being influenced by FoPWLs to purchase less of eight different unhealthy foods (each assessed separately). After recoding the frequency of buying foods in Mexican stores and noticing FoPWLs (i.e., "often" or "very often" vs. less often), logistic models regressed these outcomes on sociodemographics, adjusting for post-stratification weights. Most participants (88.0%) purchased foods in Mexican stores. Of these, 64.1% reported noticing FoPWLs, among whom many reported that FoPWLs influenced them to buy fewer unhealthy foods (range = 32% [snacks like chips] - 44% [colas]). Participants were more likely to buy foods in Mexican stores and notice FoPWLs if they were younger, had ≥two children at home vs no children (AOR = 1.40, 95%CI = 1.15–1.71; AOR = 1.37, 95%CI = 1.03–1.80, respectively), and more frequently used Spanish (AOR = 1.91, 95%CI = 1.77–2.07; AOR = 1.87, 95%CI = 1.69–2.07). Also, high vs. low education (AOR = 1.51, 95%CI = 1.17–1.94) and higher income adequacy (AOR = 1.37, 95%CI = 1.25–1.51) were positively associated with noticing FoPWLs. Being female and more frequent Spanish use were consistently associated with reporting purchase of fewer unhealthy foods because of FoPWLs. Many Mexican Americans report both exposure to Mexican FOPWLs and reducing purchases of unhealthy foods because of them. • In 2020, Mexico adopted front-of-package warning labels (FoPWL) for packaged foods. • 64% of Mexican Americans who shop in Mexican stores noticed the Mexican FoPWLs. • Many reported buying less of a range of unhealthy foods because of the Mexican FoPWLs. • FoPWLs may better address nutrition-related disparities than other labeling systems. [ABSTRACT FROM AUTHOR]

Deaths attributable to unhealthful eating underscore the need to improve dietary patterns through upstream, policy-led solutions. The approval and successful implementation of food policies is partly determined by their public acceptance. Little is known about public support for food policies in Mexico. We aimed to investigate the level of public support for 30 food policies, grouped into 5 domains, and their associated characteristics among Mexican adults. Data are from the 2017–2021 International Food Policy Study (IFPS), a cross-sectional web-based survey of adults. Differences in public support across years were estimated using linear regression models. The association between demographic characteristics and policy support was analyzed using multivariate logistic regression models. The highest mean support was for the subsidies and benefits domain, followed by the labelling and reformulation domain. The level of support varied across years and policy domains. Support was higher in 2019 compared to 2017 and 2018, and subsequently lower in 2020 and 2021 compared to previous years. Older age was associated with greater support across all domains (OR ranged from 0.002 to 0.004, p < 0.01). Female participants and those selfidentifying as indigenous showed greater support for certain policy domains, whereas higher income adequacy was associated with lower support for other policy domains. In Mexico, support for food policies varies across subpopulations. Our findings may serve as a guide to the development and promotion of food policies in Mexico, as well as to improve their feasibility and success. [ABSTRACT FROM AUTHOR]

Background Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change. Objective Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up. Methods We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered. Results Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted OR s ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence. Conclusion Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts. [ABSTRACT FROM AUTHOR]

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used. [ABSTRACT FROM AUTHOR]

This study evaluated the relationship between interpersonal communication about cigarette health warning labels (HWLs), psychological responses to HWLs, and smoking cessation attempts. Data were analyzed from online consumer panels of adult smokers in Australia, Canada and Mexico, during implementation of new pictorial health warning labels (HWLs) on cigarette packs. Approximately 1000 adult smokers were surveyed in each country every four months (September 2012, January 2013, May 2013, September 2013, January 2014). Only smokers followed for at least two waves were included in the analytic sample. Participants reported the frequency of talking about HWLs in the last month (in general, with family members, and with friends). For each country, poisson generalized estimating equation (GEE) models were estimated to assess the bivariate and adjusted correlates of talking about HWLs. Logistic GEE models regressed having attempted to quit by the subsequent wave on HWL talk, sociodemographics and psychological responses to HWLs. The frequency of HWL talk gradually decreased in Canada (48%–36%) after new HWLs were implemented; an increase (30%–58%) in Australia corresponded with implementation of new HWLs, after which talking stabilized; and the frequency of HWL talk in Mexico was stable over time, where new HWLs are implemented every six months. Talk about HWLs was an independent predictor of subsequent quit attempts in Canada (AOR = 1.50; 95% CI = 1.11–2.02), Australia (AOR = 1.41; 95% CI = 1.05–1.89), and Mexico (AOR = 1.53; 95% CI = 1.11–2.10), as was cognitive responses to HWLs (Australia AOR = 1.66; 95% CI = 1.22–2.24; Canada AOR = 1.56; 95% CI = 1.15–2.11; Mexico AOR = 1.30; 95% CI = 0.91–1.85). No interaction between talk and cognitive reactions to HWLs were found. These results suggest that interpersonal communication about HWLs influences smoking cessation attempts independent of other established predictors of smoking cessation, including cessation-related HWL responses. Future research should determine ways to catalyze interpersonal communication about HWLs and thereby potentiate HWL effects. [ABSTRACT FROM AUTHOR]

Exposure to unhealthy food and beverage marketing is an important environmental determinant of dietary intake. The current study examined self-reported exposure to marketing of unhealthy foods and beverages across various media channels and settings among parents of children younger than 18 years in five high and upper-middle income countries. Data from 4827 parents living with their children were analyzed from the International Food Policy Study (2017), a web-based survey of adults aged 18-64 years from Canada, the United States (US), the United Kingdom (UK), Australia, and Mexico. Respondents reported their exposure to marketing of fast food and of sugary drinks across media channels/settings overall and how often they see fast food and sugary drink marketing while viewing media with their children. Regression models examined differences across countries and correlates of marketing exposure. Parents in Mexico and the US reported greater exposure to marketing for fast food and sugary drinks compared to parents in Australia, Canada, and the UK. Patterns of exposure among parents were generally consistent across countries, with TV, digital media, and radio being the most commonly reported media channels for both fast food and sugary drinks. Exposure to marketing of fast food and sugary drinks was associated with a variety of sociodemographic factors, most strongly with ethnicity and education, and sociodemographic trends differed somewhat between countries. The findings demonstrate differences in self-reported parental exposure to marketing of fast food and sugary drinks between countries, and may help to evaluate the impact of marketing restrictions implemented over time. [ABSTRACT FROM AUTHOR]

Background: Aguas frescas are Mexican drinks that are typically made with water, sugar, and fruit. Aguas frescas may be a significant component of sugary-drink intake among Mexican and Mexican-American (MA) adults. However, it is unclear whether survey respondents report aguas frescas consumption when it is not specifically queried in standardized beverage frequency instruments., Objectives: This study examined the prevalence of aguas frescas consumption, the sociodemographic correlates of aguas frescas intake, and how specifically querying aguas frescas intake affects sugary-drink estimates among Mexican and MA adults., Methods: Cross-sectional, online surveys were conducted in 2021 with 5377 Mexican and 3073 MA adults as part of the International Food Policy Study. Past 7-d consumption of sugar-sweetened beverages (SSBs), sugary drinks, and aguas frescas were assessed along with relevant covariates. Weighted analyses included logistic and linear regression, including models with correlation structure., Results: An estimated 61.7% of Mexican and 28.7% of MA adults consumed aguas frescas. In Mexico, consumption was associated with females, low education, perceiving oneself as having about the right weight, being good to excellent health, and consuming an unhealthy amount of sugary drinks. For MAs, intake was associated with being younger, speaking Spanish, and perceiving oneself as being underweight or about the right weight. Among Mexican adults who consumed aguas frescas but did not report them unless specifically queried, the volume of SSB intake was 67.9% higher for females and 64.3% higher for males when aguas frescas were included. Among MAs, SSB intake was 56.9% higher for females and 44.1% higher for males. Most participants (79.9%-85.2%) remained in the same sugary-drink tertiles when including compared with excluding aguas frescas., Conclusions: Aguas frescas should be queried during beverage intake assessments, as they contribute a nontrivial amount of added sugars to the diets of many Mexican and MA adults., (Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Disruptions from the coronavirus disease 2019 (COVID-19) pandemic potentially exacerbated food insecurity among adults and youth., Objectives: The objective was to examine changes in the prevalence and severity of food insecurity among adults and youth from before (2019) to during (2020) the pandemic in multiple countries., Methods: Repeated cross-sectional data were collected among adults aged 18-100 y (n = 63,278) in 5 countries in November to December in 2018-2020 and among youth aged 10-17 y (n = 23,107) in 6 countries in November to December in 2019 and 2020. Food insecurity in the past year was captured using the Household Food Security Survey Module and the Child Food Insecurity Experiences Scale. Changes in the prevalence and severity of food insecurity were examined using logistic and generalized logit regression models, respectively. Models included age, gender, racial-ethnic identity, and other sociodemographic characteristics associated with food insecurity to adjust for possible sample differences across waves. Models were weighted to reflect each country's population., Results: Adults [adjusted OR (AOR): 1.15; 95% CI: 1.02, 1.31] and youth (AOR: 1.43; 95% CI: 1.19, 1.71) in Mexico were more likely to live in food-insecure households in 2020 compared to 2019. Adults in Australia (AOR: 0.81; 95% CI: 0.72, 0.92) and Canada (AOR: 0.87; 95% CI: 0.77, 0.99) were less likely to live in food-insecure households in 2020. Trends in severity aligned with changes in prevalence, with some exceptions. Youth in Australia (AOR: 2.24; 95% CI: 1.65, 3.02) and the United States (AOR: 1.39; 95% CI: 1.04, 1.86) were more likely to have many compared with no experiences of food insecurity in 2020 compared to 2019. There was no evidence of change among adults and youth in the remaining countries., Conclusions: Except for Mexico, few changes in food insecurity among adults and youth were observed from before to during the COVID-19 pandemic. Action is needed to support households at risk of food insecurity., (Copyright © 2023 American Society for Nutrition. All rights reserved.)

Background: Food marketing increases product appeal, purchasing, and consumption, using diverse strategies and locations to reach consumers., Objectives: The aim of this study was to examine differences in adults' self-reported exposure to various marketing strategies (brand and licensed characters, celebrities, and sponsorship of sports and cultural events) and locations (television, radio, and digital media) across 5 countries: Australia, Canada, Mexico, the United Kingdom, and the United States., Methods: We analyzed cross-sectional survey data on self-reported exposure to food marketing strategies and locations collected in 2018 by the International Food Policy Study. Participants (n = 21,678) aged ≥18 years completed an online survey. Exposures to unhealthy food marketing strategies and locations in the prior 30 days were self-reported. Regression models examined differences in marketing exposure and locations across countries., Results: The average number of unhealthy food marketing strategies to which participants reported being exposed ranged from 0.5 in the United Kingdom to 2.3 in Mexico. Self-reported exposure to strategies across all countries was highest for brand characters (32%), followed by licensed characters (22%). In total, the reported mean exposure of marketing locations was 1.6 in the prior month. Television was the most prevalent location (44%), followed by digital marketing (32%). Adjusted models indicated that the odds of reporting exposure to marketing strategies and marketing locations were higher for Mexico compared to the rest of the countries., Conclusions: Adults report a variety of exposures to unhealthy food marketing in all countries, but exposure was highest in Mexico. Special attention should be paid to regulating marketing strategies, such as brand characters and licensed characters, and locations, such as television and digital marketing., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Online food delivery services like Just Eat and Grubhub facilitate online ordering and home delivery of food prepared away-from-home. It is poorly understood how these services are used and by whom. This study investigated the prevalence of online food delivery service use and sociodemographic characteristics of customers, in and across Australia, Canada, Mexico, the UK, and the USA. We analyzed online survey data ( n = 19,378) from the International Food Policy Study, conducted in 2018. We identified respondents who reported any online food delivery service use in the past 7 days and calculated the frequency of use and number of meals ordered. We investigated whether odds of any online food delivery service use in the past 7 days differed by sociodemographic characteristics using adjusted logistic regression. Overall, 15% of respondents ( n = 2929) reported online food delivery service use, with the greatest prevalence amongst respondents in Mexico ( n = 839 (26%)). Online food delivery services had most frequently been used once and the median number of meals purchased through this mode of order was two. Odds of any online food delivery service use were lower per additional year of age (OR: 0.95; 95% CI: 0.94, 0.95) and greater for respondents who were male (OR: 1.50; 95% CI: 1.35, 1.66), that identified with an ethnic minority (OR: 1.57; 95% CI: 1.38, 1.78), were highly educated (OR: 1.66; 95% CI: 1.46, 1.90), or living with children (OR: 2.71; 95% CI: 2.44, 3.01). Further research is required to explore how online food delivery services may influence diet and health.

Background: Poor diet is a significant contributor to the burden of global disease. There are numerous policies available to address poor diets; however, these policies often require public support to encourage policy action. The current study aimed to understand the level of public support for a range of food policies and the factors associated with policy support., Methods: An online survey measuring support for 13 food policies was completed by 19,857 adults in Australia, Canada, Mexico, the United Kingdom (UK) and the United States (US). The proportion of respondents that supported each policy was compared between countries, and the association between demographic characteristics and policy support was analysed using multivariate logistic regression., Results: The level of support varied between policies, with the highest support for policies that provided incentives (e.g., price subsidies) or information (e.g., calorie labelling on menus), and the lowest support for those that imposed restrictions (e.g., restrictions on sponsorship of sport events). This pattern of support was similar in all countries, but the level differed, with Mexico generally recording the highest support across policies, and the US the lowest. Several demographic characteristics were associated with policy support; however, these relationships varied between countries., Conclusion: The results suggest that support for food policies is influenced by several factors related to the policy design, country, and individual demographic characteristics. Policymakers and advocates should consider these factors when developing and promoting policy options.

Introduction: More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images., Methods: Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses., Results: Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent., Conclusions: The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions., Implications: Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: This study examined smokers' responses to pictorial health warnings (PHWs) with different types of imagery under natural exposure conditions., Methods: Adult smokers from online panels in Canada (n=2357), Australia (n=1671) and Mexico (n=2537) were surveyed every 4 months from 2012 to 2013. Participants were shown PHWs on packs in their respective countries and asked about: (1) noticing PHWs; (2) negative affects towards PHWs; (3) believability of PHWs; (4) PHW-stimulated discussions; and (5) quit motivation due to PHWs. Country-specific generalised estimating equation models regressed these outcomes on time (ie, survey wave), PHW imagery type (ie, symbolic representations of risk, suffering from smoking and graphic depictions of bodily harm) and interactions between them., Results: In all countries, PHW responses did not significantly change over time, except for increased noticing PHWs in Canada and Mexico, increased negative affect in Australia and decreased negative affect in Mexico. For all outcomes, symbolic PHWs were rated lower than suffering and graphic PHWs in Canada (the only country with symbolic PHWs). Graphic PHWs were rated higher than suffering PHWs for negative affect (all countries), discussions (Canada) and quit motivation (Australia). Suffering PHWs were rated higher than graphic PHWs for noticing PHWs (Canada), believability (all countries), discussions (AustraliaandMexico) and quit motivation (Mexico). Changes in noticing, believability and discussions varied somewhat by imagery type across countries., Conclusions: The different PHW imagery appears to have different pathways of influence on adult smokers. Reactions to specific PHWs are similar over 1-2 years, suggesting that wear-out of PHW effects is due to decreased attention rather than the diminishing effectiveness of content., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Studies examining cigarette package pictorial health warning label (HWL) content have primarily used designs that do not allow determination of effectiveness after repeated, naturalistic exposure. This research aimed to determine the predictive and external validity of a pre-market evaluation study of pictorial HWLs., Methods: Data were analyzed from: (1) a pre-market convenience sample of 544 adult smokers who participated in field experiments in Mexico City before pictorial HWL implementation (September 2010); and (2) a post-market population-based representative sample of 1765 adult smokers in the Mexican administration of the International Tobacco Control Policy Evaluation Survey after pictorial HWL implementation. Participants in both samples rated six HWLs that appeared on cigarette packs, and also ranked HWLs with four different themes. Mixed effects models were estimated for each sample to assess ratings of relative effectiveness for the six HWLs, and to assess which HWL themes were ranked as the most effective., Results: Pre- and post-market data showed similar relative ratings across the six HWLs, with the least and most effective HWLs consistently differentiated from other HWLs. Models predicting rankings of HWL themes in post-market sample indicated: (1) pictorial HWLs were ranked as more effective than text-only HWLs; (2) HWLs with both graphic and "lived experience" content outperformed symbolic content; and, (3) testimonial content significantly outperformed didactic content. Pre-market data showed a similar pattern of results, but with fewer statistically significant findings., Conclusions: The study suggests well-designed pre-market studies can have predictive and external validity, helping regulators select HWL content., (© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Concern over health risks is the most common motivation for quitting smoking. Health warnings on tobacco packages are among the most prominent interventions to convey the health risks of smoking. Face-to-face surveys were conducted in Mexico (n = 1,072), and a web-based survey was conducted in the US (n = 1,449) to examine the efficacy of health warning labels on health beliefs. Respondents were randomly assigned to view two sets of health warnings (each with one text-only warning and 5-6 pictorial warnings) for two different health effects. Respondents were asked whether they believed smoking caused 12 different health effects. Overall, the findings indicate high levels of health knowledge in both countries for some health effects, although significant knowledge gaps remained; for example, less than half of respondents agreed that smoking causes impotence and less than one third agreed that smoking causes gangrene. Mexican respondents endorsed a greater number of correct beliefs about the health effects of smoking than did the U.S. sample. In both countries, viewing related health warning labels increased beliefs about the health risks of smoking, particularly for less well-known health effects such as gangrene, impotence, and stroke.