title: Investigating the effectiveness of pictorial health warnings in Mauritius: findings from the ITC Mauritius survey.
abstract: BACKGROUND
  Health warnings on tobacco packages are an effective strategy for informing the public about the harms associated with tobacco use. Most studies investigating the effectiveness of pictorial health warnings (PHWs) on cigarette packages are from high-income countries. This study evaluated the impact of PHWs on smokers' perceptions and behavior in Mauritius, the first country in the World Health Organization African region to implement PHWs.
  
  
  METHODS
  Data were drawn from 3 waves of a nationally representative cohort of adult smokers from the International Tobacco Control (ITC) Mauritius Survey (n = 668). Wave 1 was conducted in 2009, 6 months prior to the implementation of PHWs. Waves 2 and 3 were conducted 10-12 months and 20-21 months, respectively, postimplementation. Six established indicators of warning effectiveness were used to evaluate the effect of PHWs on smokers' perceptions and behavior.
  
  
  RESULTS
  All indicators of warning effectiveness (salience, cognitive, and behavioral reactions) and the Label Impact Index, a weighted combination of 4 indicators, increased significantly between Waves 1 and 2. However, between Waves 2 and 3, there was a significant decline in the proportion of smokers who reported "avoiding looking" at labels.
  
  
  CONCLUSIONS
  This study found that implementation of PHWs in Mauritius significantly enhanced the effectiveness of warnings, illustrating their value for other countries, particularly in Africa, at an early stage in tobacco control. The study also demonstrates the importance of revising PHWs to counteract wearout. The introduction of PHWs in Mauritius clearly demonstrates the benefits of employing an evidence-based approach to strengthen tobacco control policies.
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada; a7green@uwaterloo.ca.
authors.forename: Annika C
authors.initials: AC
authors.lastname: Green
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada;
authors.forename: Susan C
authors.initials: SC
authors.lastname: Kaai
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada; School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada;
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Fong
authors.affiliation: Propel Centre for Population Health Impact, University of Waterloo, Waterloo, Ontario, Canada;
authors.forename: Pete
authors.initials: P
authors.lastname: Driezen
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada;
authors.forename: Anne C K
authors.initials: AC
authors.lastname: Quah
authors.affiliation: Mauritius Institute of Health, Pamplemousses, Mauritius.
authors.forename: Premduth
authors.initials: P
authors.lastname: Burhoo
mesh_terms: D000293:Adolescent; D000328:Adult; D003625:Data Collection; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008436:Mauritius; D008875:Middle Aged; D011356:Product Labeling; D012907:Smoking / Q000523:psychology*; D016540:Smoking Cessation / Q000523:psychology*; D062789:Tobacco Products; D055815:Young Adult
references.citation: Tob Control. 2010 Oct;19 Suppl 2:i69-77
references.pmid: 20935200
references.citation: Salud Publica Mex. 2007;49 Suppl 2:S233-40
references.pmid: 17607485
references.citation: Nicotine Tob Res. 2013 Aug;15(8):1339-47
references.pmid: 23291637
references.citation: Prim Care Respir J. 2013 Sep;22(3):300-5
references.pmid: 23817677
references.citation: Addiction. 2002 Dec;97(12):1561-71
references.pmid: 12472640
references.citation: Addiction. 2009 Apr;104(4):669-75
references.pmid: 19215595
references.citation: Tob Control. 2006 Jun;15 Suppl 3:iii19-25
references.pmid: 16754942
references.citation: Salud Publica Mex. 2010;52 Suppl 2:S206-15
references.pmid: 21243191
references.citation: Tob Control. 2011 Sep;20(5):327-37
references.pmid: 21606180
references.citation: Tob Control. 2003 Dec;12(4):391-5
references.pmid: 14660774
references.citation: Int J Environ Res Public Health. 2010 Nov;7(11):4089-99
references.pmid: 21139879
references.citation: Bull World Health Organ. 2009 Aug;87(8):640-3
references.pmid: 19705020
references.citation: Tob Control. 2009 Oct;18(5):358-64
references.pmid: 19561362
references.citation: Am J Prev Med. 2007 Mar;32(3):202-9
references.pmid: 17296472
references.citation: Int J Environ Res Public Health. 2011 Nov;8(11):4312-31
references.pmid: 22163209
references.citation: Tob Control. 2006 Jun;15 Suppl 3:iii3-11
references.pmid: 16754944
references.citation: Nicotine Tob Res. 2014 May;16(5):536-43
references.pmid: 24323572
references.citation: Soc Sci Med. 2008 Apr;66(8):1772-83
references.pmid: 18249479