title: Educating smokers about the risk of blindness - insights to improve tobacco product health warning labels.
abstract: BACKGROUND
  Health warning labels (HWL) on tobacco products help educate smokers about the health effects from smoking; however, there is a need to improve HWL content including images and text to increase effectiveness. In Canada, a HWL was created that communicates smoking's causal association with "blindness" from age-related macular degeneration (AMD). This study surveyed Canadian optometrists about their opinions regarding the image and text used in the "blindness" HWL.
  
  
  METHODS
  An online survey was sent to all 4528 registered Canadian optometrists. Respondents were asked if the HWL conveyed important and believable information, and if the picture was appropriate. Optometrists were invited to make open-ended comments about the label which were analyzed using a qualitative analysis framework suitable for health policy evaluation. Frequency distributions were calculated for closed-ended questions.
  
  
  RESULTS
  The survey was completed by 850 respondents (19 %). Most respondents (90 %) reported the message was believable/somewhat believable; while 35 % felt the picture was "too graphic". Some respondents reported in their open-ended comments that they were concerned the HWL was internally inconsistent because it reports there is "no effective treatment in most cases" for AMD but the image depicts someone undergoing surgery. There was concern that this may discourage patients from seeking needed treatment.
  
  
  CONCLUSIONS
  The majority of Canadian optometrist respondents were in agreement that the new, "RISK OF BLINDNESS" pictorial HWL includes important, believable information. Some optometrists had concerns that the HWL included a confusing message or a message that may discourage some patients from pursuing treatment for AMD. Future development of blindness-related HWL should seek practitioner input.
authors.affiliation: Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON N2L 3G1 Canada ; Institute for Global Tobacco Control, Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA.
authors.forename: Ryan David
authors.initials: RD
authors.lastname: Kennedy
authors.affiliation: School of Public Health and Health Systems, University of Waterloo, Waterloo, ON N2L 3G1 Canada.
authors.forename: David
authors.initials: D
authors.lastname: Hammond
authors.affiliation: Faculty of Science, University of Waterloo, Waterloo, ON N2L 3G1 Canada.
authors.forename: Marlee M
authors.initials: MM
authors.lastname: Spafford
authors.affiliation: Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON N2L 3G1 Canada.
authors.forename: Ornell
authors.initials: O
authors.lastname: Douglas
authors.affiliation: École d'optométrie, Université de Montréal, Montréal, QC H3T 1P1 Canada.
authors.forename: Julie
authors.initials: J
authors.lastname: Brûlé
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1 Canada ; Ontario Institute for Cancer Research, Toronto, Ontario M5G 0A3 Canada.
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Fong
authors.affiliation: College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3T 2N2 Canada.
authors.forename: Annette S H
authors.initials: AS
authors.lastname: Schultz