title: Does Reactance against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation amongst Adult Smokers in Australia, Canada, Mexico and the United States.
abstract: OBJECTIVE
  Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts.
  
  
  METHODS
  Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated.
  
  
  RESULTS
  Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance.
  
  
  CONCLUSIONS
  Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.
authors.affiliation: Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America.
authors.forename: Yoo Jin
authors.initials: YJ
authors.lastname: Cho
authors.affiliation: Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America.|Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico.
authors.forename: James F
authors.initials: JF
authors.lastname: Thrasher
authors.affiliation: Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America.
authors.forename: Kamala
authors.initials: K
authors.lastname: Swayampakala
authors.affiliation: Cancer Council Victoria, Melbourne, Victoria, Australia.
authors.forename: Hua-Hie
authors.initials: HH
authors.lastname: Yong
authors.affiliation: School of Journalism and Mass Communications, University of South Carolina, Columbia, South Carolina, United States of America.
authors.forename: Robert
authors.initials: R
authors.lastname: McKeever
authors.affiliation: School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Hammond
authors.affiliation: Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America.|Department of Health Education & Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia.
authors.forename: Dien
authors.initials: D
authors.lastname: Anshari
authors.affiliation: Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America.
authors.forename: K Michael
authors.initials: KM
authors.lastname: Cummings
authors.affiliation: Cancer Council Victoria, Melbourne, Victoria, Australia.
authors.forename: Ron
authors.initials: R
authors.lastname: Borland
mesh_terms: D000293:Adolescent; D000328:Adult; D001315:Australia; D002170:Canada; D005260:Female; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D008297:Male; D008800:Mexico; D008875:Middle Aged; D011356:Product Labeling / Q000379:methods*; D012907:Smoking / Q000523:psychology*; D016540:Smoking Cessation / Q000523:psychology* / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D014481:United States; D055815:Young Adult