title: The influence of graphic warning labels on efficacy beliefs and risk perceptions: a qualitative study with low-income, urban smokers.
abstract: BACKGROUND
  Health communication theories indicate that messages depicting efficacy and threat might promote behavior change by enhancing individuals' efficacy beliefs and risk perceptions, but this has received little attention in graphic warning label research. We explored low socioeconomic status (SES) smokers' perceptions of theory-based graphic warning labels to inform the development of labels to promote smoking cessation.
  
  
  METHODS
  Twelve graphic warning labels were developed with self-efficacy and response efficacy messages paired with messages portraying high, low, or no threat from smoking. Self-efficacy messages were designed to promote confidence in ability to quit, while response efficacy messages were designed to promote confidence in the ability of the Quitline to aid cessation. From January - February 2014, we conducted in-depth interviews with 25 low SES adult men and women smokers in Baltimore, Maryland, U.S. Participants discussed the labels' role in their self-efficacy beliefs, response efficacy beliefs about the Quitline, and risk perceptions (including perceived severity of and susceptibility to disease). Data were analyzed through framework analysis, a type of thematic analysis.
  
  
  RESULTS
  Efficacy messages in which participants vicariously experienced the characters' quit successes were reported as most influential to self-efficacy beliefs. Labels portraying a high threat were reported as most influential to participants' perceived severity of and susceptibility to smoking risks. Self-efficacy messages alone and paired with high threat were seen as most influential on self-efficacy beliefs. Labels portraying the threat from smoking were most motivational for calling the Quitline, followed by labels showing healthy role models who had successfully quit using the Quitline.
  
  
  CONCLUSIONS
  Role model-based efficacy messages might enhance the effectiveness of labels by making smokers' self-efficacy beliefs about quitting most salient and enhancing the perceived efficacy of the Quitline. Threatening messages play an important role in enhancing risk perceptions, but findings suggest that efficacy messages are also important in the impact of labels on beliefs and motivation. Our findings could aid in the development of labels to address smoking disparities among low SES populations in the U.S.
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins University, Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205 U.S.A. ; Department of Behavioral and Community Health, University of Maryland School of Public Health, Tobacco Center of Regulatory Science, SPH Building (255), 4200 Valley Drive, College Park, MD 20742-2611 U.S.A.
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, 2213 McElderry St., Fourth Floor, Baltimore, MD 21205 U.S.A.
authors.forename: Joanna E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205 U.S.A.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.affiliation: Department of Mental Health, Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205 U.S.A.
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, 624 N. Broadway, Baltimore, MD 21205 U.S.A.
authors.forename: Carl A
authors.initials: CA
authors.lastname: Latkin