title: The appeal of smokeless tobacco products among young Canadian smokers: the impact of pictorial health warnings and relative risk messages.
abstract: BACKGROUND
  Although the health risks from smokeless tobacco (ST) are lower than cigarettes, it remains unclear how smokers might use ST products, including as a substitute, a cessation aid, or concurrently with cigarette use, if at all. Additionally, there is little evidence examining the impact of health warning labels (HWL) on ST use and perceptions.
  
  
  METHODS
  The current study investigated perceptions of ST products with and without HWL and a relative health risk (RHR) message. The study consisted of a full-factorial "between-subjects" experiment in which 3 HWL and a RHR message were systematically varied. Canadian smokers aged 18-30 years (N = 611) completed an online survey where they viewed four brands of ST packages altered according to the experimental conditions.
  
  
  RESULTS
  Approximately half of the smokers indicated that they were willing to try ST as a substitute and to help quit smoking. More than one quarter (28%) of smokers were unaware that using ST is less harmful than smoking. Pictorial HWL increased false beliefs about the RHR of ST and decreased smokers' willingness to try ST, whereas text warnings did not. Adding a RHR message communicating the lower risk of ST compared with cigarettes increased willingness to try ST when added to text HWL but decreased willingness to try ST even further when added to pictorial HWL.
  
  
  CONCLUSIONS
  The findings indicate relatively high levels of appeal for ST among young adult Canadian cigarette smokers. Pictorial HWL reduced the appeal of ST products and increased perceived risks, including the false belief that ST is equally harmful as cigarettes. Further research could consider evaluating designs of HWL on ST products that better balance absolute and RHR.
authors.affiliation: Department of Health Studies and Gerontology, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, Canada N2L 3G1.
authors.forename: William E
authors.initials: WE
authors.lastname: Callery
authors.forename: David
authors.initials: D
authors.lastname: Hammond
authors.forename: Richard J
authors.initials: RJ
authors.lastname: O'Connor
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Fong
mesh_terms: D000293:Adolescent; D000328:Adult; D001296:Audiovisual Aids; D002170:Canada; D003625:Data Collection; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods; D006801:Humans; D011356:Product Labeling; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation / Q000379:methods; D000074606:Smoking Prevention; D012938:Social Perception; D014030:Tobacco, Smokeless / Q000009:adverse effects*; D055815:Young Adult