Eye (2010) 24, 864–868 & 2010 Macmillan Publishers Limited All rights reserved 0950-222X/10 $32.00 www.nature.com/eye 1,2 1 2,3 CLINICAL STUDY Awareness of DHL Ng , STD Roxburgh , S Sanjay and KG Au Eong2,3,4,5 smoking risks and attitudes towards graphic health warning labels on cigarette packs: a cross-cultural study of two populations in Singapore and Scotland Abstract Conclusion Graphic health warning labels reading ‘Smoking causes blindness’ printed 1Ninewells Hospital and Background Little is known about the level on cigarette packs may be useful in raising Medical School, University of awareness of blindness as a smoking- public awareness of blindness as a smoking- of Dundee, Dundee, UK related condition, although the relationship related condition and discouraging the habit has been well established. 2Department of of smoking in Singapore and Scotland. Aim To compare the awareness of smoking Ophthalmology and Visual Eye (2010) 24, 864–868; doi:10.1038/eye.2009.208; Sciences, Alexandra risks and the impact of graphic health warning published online 21 August 2009 Hospital, Singapore labels on cigarette packs in discouraging smoking among adults in Singapore and 3 Keywords: awareness; blindness; smoking Jurong Medical Centre, Scotland. cessation; graphic health warning labels; Singapore Methods A cross-sectional survey using a motivation structured interview of adults in ophthalmic, 4Department of Ophthalmology, Yong Loo general medical, and general surgical outpatient clinics in Singapore and Lin School of Medicine, Introduction National University of Scotland. Singapore, Singapore Results One hundred and fifteen out of 163 Smoking is known to be a risk factor for (70.6%) outpatients in Singapore and 105 out respiratory, cardiovascular, and malignant 5 Singapore International Eye of 112 (93.8%) outpatients in Scotland diseases. In addition, some studies have also Cataract Retina Centre, Singapore responded to the study. In both samples, shown a strong association between smoking awareness levels for smoking-related diseases and ocular diseases such as age-related macular Correspondence: DHL Ng, such as lung cancer, mouth and throat cancer, degeneration, cataract, Graves’ ophthal- Ninewells Hospital and heart disease, and stroke were all greater than mopathy, and glaucoma.1 Medical School, University 85%. These were found to be significantly Despite this relationship, much of the general of Dundee, Dundee higher than the level of awareness of public is unaware of this link, compared with DD1 9SY Scotland, UK Tel: þ 44(0)1382 801336; blindness as a smoking-related condition other more well-known conditions such as lung 2 2 Fax: þ 65 64663695. (v -test, Po0.001). Although the awareness of cancer, oral cancer, stroke, and heart attack. E-mail: eyesofchinablue@ blindness as a smoking-related condition was A recent British study on 260 teenagers showed gmail.com greater in Singapore (36.5%) than in Scotland that although 81, 27, and 15% believed that (30.5%), this difference was not statistically smoking causes lung cancer, heart disease, and Received: 1 February 2009 significant. More than half of the respondents stroke, respectively, only 5% were aware that it Accepted in revised form: 8 July 2009 indicated that graphic health warning labels causes blindness. However, the teenagers were Published online: 21 August would be effective in discouraging them from significantly more fearful of blindness than of 2009 smoking. lung cancer, heart disease, or stroke. In addition, Awareness of smoking risks DHL Ng et al 865 more teenagers said they would stop smoking on were asked to grade how harmful they thought smoking developing early signs of blindness compared with was to health on a scale of 0–10 (with 0 being ‘not early signs of lung cancer, heart disease, and stroke.3 harmful’ and 10 ‘harm resulting in death’) and their In view of this, it is important to raise the awareness opinion of whether they believed there was a link of the relationship between smoking and blindness, between smoking and six medical conditionsFnamely and to encourage smoking cessation. heart disease, stroke, lung cancer, mouth and throat In an effort to discourage smoking, a number of cancer, blindness, and deafness. Subjects were then asked countries such as Australia, Canada, Brazil, and to choose the one condition that they would prevent if it Singapore have used graphic health warning labels to was possible to prevent only one, as well as the one educate the public about the health hazards of smoking. condition for which they would seek treatment for if it Such labels were first printed in Singapore in 2004 and was possible to treat only one. They were then asked to subsequently revised in 2006.4 In addition, recent rank the six conditions in order from the one they feared legislation passed in the United Kingdom will also most (1) to the one they feared least (6). require cigarette packs to carry such labels by 2009.5 In Following this, subjects were shown warning labels 2001, a study conducted in Canada revealed that graphic that have been used on cigarette packs in Australia.9 health warning labels were effective in discouraging They were then asked for their response to the warning smoking among smokers, with approximately one-fifth labels with respect to the amount of fear and disgust of smokers decreasing their cigarette consumption as a experienced, as well as the level of motivation that the result of the labels.6 Singapore and Scotland are both warning labels would provide to non- and ex-smokers to countries in the developed world with differing discourage them from smoking and to current smokers to approaches to tobacco control, as well as a significant encourage them to quit smoking. These were graded on a difference in the prevalence of smoking between the two scale of 0–10 (with 0 being ‘not at all’ and 10 being ‘a lot’). countries (13% in Singapore7 and 25% in Scotland8). The graphic warnings were as follows: ‘Smoking causes This cross-sectional study conducted in Singapore and heart disease’, ‘Smoking causes blindness’, ‘Smoking Scotland aims at exploring the level of awareness among causes lung cancer’, ‘Smoking causes mouth and throat adult outpatients on the association between smoking cancer’, and ‘Smoking doubles your risk of stroke’. and blindness, as well as their response to graphic health Respondents in Singapore were also asked if they had warning labels discouraging smoking. actively avoided looking at the warning labels already in use on cigarette packs. Materials and methods Statistical analysis Subjects and setting All data collected from both study sites were analysed Adults attending ophthalmic, general medical, and using Microsoft Excel 2000 (Microsoft Corporation, USA). general surgical outpatient clinics from November 2007 Ethics approval for this study was obtained from the to February 2008 in Alexandra Hospital, Singapore and Domain Specific Review Board in Singapore and the Ninewells Hospital, Scotland were invited to participate NHS Tayside Committee on Medical Research Ethics in in the study. Participants between the ages of 21 and 80 Scotland. Permission for the use of the Australian years were included and those unable to give written graphic health warning labels in this study was also informed consent or complete the questionnaire were obtained from the Australian government. excluded. Alexandra Hospital serves a population of about 310 000 in mid-western and southern Singapore, and Results Ninewells Hospital serves a population of 400 000 in east-central Scotland. Response and demographic profile The response rates among those eligible to participate were 70.6% (115/163) in Singapore and 93.8% (105/112) Data collection in Scotland. In Singapore, the majority of interviews were Data from randomly selected participants were collected conducted in English. Thirteen percent (15/115) of the using a structured interview, which included the interviews were conducted in Mandarin for respondents participant’s demographic details and smoking status. who did not possess an adequate understanding of the All interviews were conducted by the same interviewer English language, with the content of the graphic (DHLN). The setup of the questionnaire was based partly warnings translated into Mandarin. All interviews in on that used by Bidwell et al2 and Moradi et al.3 Subjects Scotland were conducted in English. The respondents’ Eye Awareness of smoking risks DHL Ng et al 866 Table 1 Participants’ demographic profile and smoking status There was a significant difference between the proportion of Singaporean and Scottish participants Singapore (N ¼ 115) Scotland (N ¼ 105) who believed that deafness was related to smoking Mean age (range, years) 49.8 (21–75) 54.8 (21–78) (w2-test, Po0.001). This tendency of Singaporean participants to associate deafness with smoking Sex (N) Male 57 54 may suggest (but does not prove) a general tendency Female 58 51 to over-associate all the study conditions to smoking in this study population. Alternatively, it may be Ethnicity (N) an indication that Singaporean participants are more Caucasian 1 105 aware of the growing body of evidence linking deafness Chinese 81 0 10 Malay 15 0 to smoking. Indian 14 0 Others 5 0 Ranking of fear of smoking-related conditions Smoking status (N) Of the six diseases, majority of respondents in both Current smoker 5 21 Ex-smoker 22 36 populations would choose to both prevent Non-smoker 88 48 (SingaporeF32.2%; ScotlandF38.1%) and treat (SingaporeF32.2%, ScotlandF40.1%) lung cancer first. Although lung cancer and heart disease were the two demographic details and smoking status are listed in most feared conditions in both populations, the two Table 1. populations differed on the ranking of the third most The respondents in Singapore were predominantly feared condition, this being stroke (18.3%) and blindness Chinese, while all respondents in Scotland were (17.1%) in Singapore and Scotland, respectively.