title: The role of theory-driven graphic warning labels in motivation to quit: a qualitative study on perceptions from low-income, urban smokers.
abstract: BACKGROUND
  Use of communication theories in the development of pictorial health warning labels (graphic warning labels) for cigarette packaging might enhance labels' impact on motivation to quit, but research has been limited, particularly among low socioeconomic status (SES) populations in the U.S. This qualitative study explored perceptions of theory-based graphic warning labels and their role in motivation to quit among low-income smokers.
  
  
  METHODS
  A cross-sectional qualitative study was conducted with 25 low-income adult smokers in Baltimore, Maryland, who were purposively sampled from a community-based source population. Semi-structured, in-depth interviews were conducted from January to February 2014. Participants were asked about the motivational impact of 12 labels falling into four content categories: negative depictions of the health effects of smoking to smokers and others, and positive depictions of the benefits of quitting to smokers and others. Data were coded using a combined inductive/deductive approach and analyzed thematically through framework analysis.
  
  
  RESULTS
  Labels depicting negative health effects to smokers were identified as most motivational, followed by labels depicting negative health effects to others. Reasons included perceived severity of and susceptibility to the effects, negative emotional reactions (such as fear), and concern for children. Labels about the benefits of quitting were described as motivational because of their hopefulness, characters as role models, and desire to improve family health. Reasons why labels were described as not motivational included lack of impact on perceived severity/susceptibility, low credibility, and fatalistic attitudes regarding the inevitability of disease.
  
  
  CONCLUSIONS
  Labels designed to increase risk perceptions from smoking might be significant sources of motivation for low SES smokers. Findings suggest innovative theory-driven approaches for the design of labels, such as using former smokers as role models, contrasting healthy and unhealthy characters, and socially-oriented labels, might motivate low SES smokers to quit.
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. emead1@umd.edu.|Tobacco Center of Regulatory Science, Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD, 20742-2611, USA. emead1@umd.edu.
authors.forename: Erin L
authors.initials: EL
authors.lastname: Mead
authors.affiliation: Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. jcohen@jhu.edu.
authors.forename: Joanna E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. caitlinkennedy@jhu.edu.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.affiliation: Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA. jgallo2@jhu.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Gallo
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA. carl.latkin@jhu.edu.
authors.forename: Carl A
authors.initials: CA
authors.lastname: Latkin
mesh_terms: D015142:Baltimore; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008960:Models, Psychological; D009042:Motivation; D010465:Perception; D011203:Poverty; D011356:Product Labeling / Q000379:methods; D019064:Product Packaging / Q000379:methods*; D036301:Qualitative Research; D012907:Smoking / Q000453:epidemiology; D016540:Smoking Cessation / Q000523:psychology*; D062789:Tobacco Products; D014481:United States; D014505:Urban Population