title: The lower effectiveness of text-only health warnings in China compared to pictorial health warnings in Malaysia.
abstract: BACKGROUND
  In 2009, China changed its health warnings on cigarette packs from side-only text warnings to two text-only warnings on 30% of the bottom of the front and back of the pack. Also in 2009, Malaysia changed from similar text warnings to pictorial health warnings consistent with Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines.
  
  
  OBJECTIVE
  To measure the impact of the change in health warnings in China and to compare the text-only health warnings to the impact of the pictorial health warnings introduced in Malaysia.
  
  
  METHODS
  We measured changes in key indicators of warning effectiveness among a longitudinal cohort sample of smokers from Waves 1 to 3 (2006-2009) of the International Tobacco Control (ITC) China Survey and from Waves 3 to 4 (2008-2009) of the ITC Malaysia Survey. Each cohort consisted of representative samples of adult (≥18 years) smokers from six cities in China (n=6575) and from a national sample in Malaysia (n=2883). Generalised Estimating Equations (GEE) were used to examine the impact of the health warnings on subsequent changes in salience of warnings, cognitive and behavioural outcomes.
  
  
  RESULTS
  Compared to Malaysia, the weak text-only warning labels in China led to a significant change in only two of six key indicators of health warning effectiveness: forgoing cigarettes and reading the warning labels. The change to pictorial health warnings in Malaysia led to significant and substantial increases in five of six indicators (noticing, reading, forgoing, avoiding, thinking about quitting).
  
  
  CONCLUSIONS
  The delay in implementing pictorial health warnings in China constitutes a lost opportunity for increasing knowledge and awareness of the harms of cigarettes, and for motivating smokers to quit.
authors.affiliation: Social and Epidemiological Research Department, Centre for Addiction and Mental Health, London, Ontario, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Tara
authors.initials: T
authors.lastname: Elton-Marshall
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Steve Shaowei
authors.initials: SS
authors.lastname: Xu
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Gang
authors.initials: G
authors.lastname: Meng
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Anne C K
authors.initials: AC
authors.lastname: Quah
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Genevieve C
authors.initials: GC
authors.lastname: Sansone
authors.affiliation: Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Guoze
authors.initials: G
authors.lastname: Feng
authors.affiliation: Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Jiang
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Pete
authors.initials: P
authors.lastname: Driezen
authors.affiliation: National Poison Centre, Universiti Sains Malaysia, Pulau Penang, Malaysia.
authors.forename: Maizurah
authors.initials: M
authors.lastname: Omar
authors.affiliation: National Poison Centre, Universiti Sains Malaysia, Pulau Penang, Malaysia.
authors.forename: Rahmat
authors.initials: R
authors.lastname: Awang
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada Ontario Institute for Cancer Research, Toronto, Ontario, Canada School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Fong
mesh_terms: D000293:Adolescent; D000328:Adult; D002681:China; D015331:Cohort Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006306:Health Surveys; D006801:Humans; D008137:Longitudinal Studies; D008296:Malaysia; D008297:Male; D008875:Middle Aged; D009042:Motivation; D011356:Product Labeling / Q000379:methods*; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation / Q000523:psychology*; D000074606:Smoking Prevention; D062789:Tobacco Products; D055815:Young Adult
keywords: Global health; Low/Middle income country; Packaging and Labelling