title: A cross-sectional survey investigating the desensitisation of graphic health warning labels and their impact on smokers, non-smokers and patients with COPD in a London cohort.
abstract: OBJECTIVE
  There is a lack of evidence regarding the effectiveness of graphic health warning labels (GHWL) in different individuals, including patients with chronic obstructive pulmonary disease (COPD). Investigating knowledge and attitudes may allow better implementation of future public health policies. We hypothesised that differences in the impact of GHWL exist between non-smokers, smokers and patients with COPD, with decreased efficacy in those groups who are longer and more frequently exposed to them.
  
  
  METHODS
  163 participants (54% male, aged 21-80) including 60 non-smokers, 53 smokers and 50 patients with COPD (Gold stage II-IV), attending London respiratory outpatient clinics, participated in case-controlled surveys (50 items).
  
  
  METHODS
  Ten different GHWL were shown and demographics, smoking history, plans to quit, smoking-risk awareness, emotional response, processing and impact of GHWL on behaviour were recorded. Patients were further asked to prioritise the hypothetical treatment or prevention of five specific smoking-related diseases.
  
  
  RESULTS
  Smokers, in particular those with COPD, were less susceptible to GHWL than non-smokers; 53.4% of all participants expressed fear when looking at GHWL, non-smokers (71.9%) more so than smokers (39.8%, p<0.001). COPD participants were less aware of the consequences than non-COPD participants (p<0.001), including an awareness of lung cancer (p=0.001). Lung cancer (95%), oral cancer (90.2%), heart disease (84.7%) and stroke (71.2%) were correctly associated with smoking, whereas blindness was least associated (23.9%). However, blindness was prioritised over oral cancer, stroke and in patients with COPD also over heart disease when participants were asked about hypothetical treatment or prevention.
  
  
  CONCLUSIONS
  GHWL are most effective in non-smokers and a desensitisation effect was observed in smokers and patients with COPD. As a consequence, a tailored and concerted public health approach to use such messages is required and 'blindness' deserves to be mentioned in this context because of an unexpectedly high-deterring impact.
authors.affiliation: Lane Fox Respiratory Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Culadeeban
authors.initials: C
authors.lastname: Ratneswaran
authors.affiliation: King's College London School of Medicine, London, UK.
authors.forename: Ben
authors.initials: B
authors.lastname: Chisnall
authors.affiliation: Lane Fox Respiratory Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Panagis
authors.initials: P
authors.lastname: Drakatos
authors.affiliation: King's College London School of Medicine, London, UK.
authors.forename: Sukhanthan
authors.initials: S
authors.lastname: Sivakumar
authors.affiliation: King's College London School of Medicine, London, UK.
authors.forename: Bairavie
authors.initials: B
authors.lastname: Sivakumar
authors.affiliation: Lane Fox Respiratory Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Miriam
authors.initials: M
authors.lastname: Barrecheguren
authors.affiliation: Department of Public Health Sciences, King's College London & NIHR Biomedical Research Centre, London, UK.
authors.forename: Abdel
authors.initials: A
authors.lastname: Douiri
authors.affiliation: Lane Fox Respiratory Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK King's College London School of Medicine, London, UK.
authors.forename: Joerg
authors.initials: J
authors.lastname: Steier
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D009042:Motivation; D011356:Product Labeling / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology / Q000534:rehabilitation*; D012907:Smoking / Q000453:epidemiology; D016540:Smoking Cessation / Q000379:methods / Q000523:psychology*; D000074606:Smoking Prevention; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: PREVENTIVE MEDICINE; PUBLIC HEALTH