City University of New York (CUNY) CUNY Academic Works All Dissertations, Theses, and Capstone Projects Dissertations, Theses, and Capstone Projects 9-2015 Investigation of the Effects of Graphic Cigarette Warning Labels on Youth and Adult Smoking Behavior in Southeast Asia Jessica Brooke Steier Graduate Center, City University of New York How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/gc_etds/1142 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] Investigation of the Effects of Graphic Cigarette Warning Labels on Youth and Adult Smoking Behavior in Southeast Asia by Jessica Steier A dissertation submitted to the Graduate Faculty in Public Health in partial fulfillment of the requirements for the degree of Doctor of Public Health, The City University of New York 2015 © 2015 Jessica Steier All Rights Reserved ii This manuscript has been read and accepted for the Graduate Faculty in Public Health in satisfaction of the dissertation requirement for the degree of Doctor of Public Health. Marianne C. Fahs ___________ ____________________________________________________ Date Chair of the Examining Committee Denis Nash ___________ ____________________________________________________ Date Executive Officer William T. Gallo Sponsor of the Examining Committee Nancy Sohler First Reader of the Examining Committee Joel Dubin Second Reader of the Examining Committee THE CITY UNIVERSITY OF NEW YORK iii Abstract Investigation of the Effects of Graphic Cigarette Warning Labels on Youth and Adult Smoking Behavior in Southeast Asia by Jessica Steier Adviser: Professor William T. Gallo, PhD The objective of this dissertation was to investigate the impact of graphic cigarette warning label policies enacted in Thailand and Malaysia on youth and adult smoking outcomes. We sought to examine the effect of the policy on youth smoking intention, susceptibility, and behaviors. Among adults, who were all baseline smokers, we sought to examine the effects of graphic warning labels on smoking intensity, quit attempts, and cessation. Secondary data were utilized from the International Tobacco Control (ITC) South East Asia (SEA) Survey, a nationally representative cohort survey for which eight years of data spanning from 2005 to 2012 were available. Multiple wave-pairs of data were analyzed concurrently using generalized estimating equations (GEEs) with the predictors measured at a baseline wave (wave t) predicting outcomes measured at the next wave, the outcome wave (wave t + 1). Thus, it was possible for participants to provide data for multiple wave-pairs which increased the power of the study. We analyzed our data using two approaches. In our first approach, we utilized a quasi- experimental design capturing the time period after which Thailand had enacted the policy, but prior to policy implementation in Malaysia. Using this approach, outcomes were assessed for our Thai sample using the Malaysian sample as a control, whereby country differences reflected the effects of the graphic warning label policy. In our second approach, we limited the data to the post-policy implementation period in both countries to assess the effect of frequency of exposure to graphic warning labels on smoking outcomes among youth and adults. We employed measures of risk cognition and label salience as proxies for frequency of exposure, due to the potential collinearity between smoking status and exposure to warning labels which may have contaminated our analyses of smoking outcomes. This study found that graphic cigarette warning labels significantly reduced future smoking intention among Thai male youth smokers, as well as increased the odds of intending to quit smoking within 6 months. Among female never-smokers, the policy decreased intention to smoke. We also found iv high cognition of risk to be significantly associated with decreased susceptibility to smoking, decreased odds of smoking initiation, and reduced smoking intensity among male youth. Among adult smokers, our findings indicate that any label salience was associated with increased odds of attributing quit status to warning labels among male smokers in Thailand and all adult smokers in Thailand (versus no salience). High label salience was associated with increased odds of making a quit attempt among male smokers in Thailand, all smokers in Thailand, and male smokers in Thailand and Malaysia (versus low salience); and increased odds of attributing quit status to warning labels among male smokers in Thailand and all adult smokers in Thailand (versus low salience). A secondary goal of our research was to explore purchasing loose cigarettes, or loosies, as an effect modifier of the association between label salience and smoking outcomes. The investigation of loosies is imperative, as some researchers have raised concerns that smokers will employ avoidance tactics such as covering cigarette packs or purchasing loosies to avoid graphic labels. Our findings indicate that loosies are actually associated with positive smoking outcomes: among smokers reporting any label salience, we found reduced odds of high intensity smoking among smokers in Thailand and Malaysia who purchased loosies (versus those who did not purchase loosies). Among respondents who reported high salience, we found reduced odds of high intensity smoking among smokers in Thailand and Malaysia who purchased loosies (versus those who did not purchase loosies). In conclusion, the findings of this study support the effectiveness of graphic cigarette warning labels in reducing intention to smoke and smoking behaviors among youth and adults in Southeast Asia. If current trends persist, tobacco will kill more than 8 million people worldwide annually by the year 2030, with 80 percent of these deaths in low- and middle-income countries. It is imperative that we continue to support the implementation of cost-effective public health policies to reverse these trends and reduce smoking-related morbidity and mortality. v Acknowledgements Of all the components of this dissertation, I find myself struggling most with the acknowledgements. It is nearly impossible to find the words to express the extent of my gratitude for my family, friends, and mentors. To my love, Ethan -- thank you for your patience and unwavering support throughout this process. Nothing brings a couple closer than simultaneously surviving a medical residency and a doctoral dissertation (not to mention planning a wedding, a cross-country move, and a career change). Late nights, weekends, and holidays spent writing at the coffee shop were made tolerable knowing that I was coming home to you (or one of your sweet notes on the bathroom mirror), cheering me along every step of the way. Thank you for riding out this rollercoaster with me. To my mother – my fire, my heart, and my soul. Despite living in different states, your presence and support were tangible over these past five years. Speaking to you (every few hours!) helped keep me sane. I’ve learned so much from you about hard work and sacrifice. To say that this journey has been difficult would an understatement -- but you taught me that the ends justify the means. At the heart of everything I do is my innate drive to help others. You instilled compassion, beneficence, and empathy in me, and for that, I will be forever grateful. Kocham cię, always and forever. To my father – my “Superman.” Your battle with emphysema will not be in vain. Watching how hard you fight on a daily basis has inspired my commitment to conducting research on tobacco control policies in the hopes of preventing others from battling smoking-related disease. You can also take full credit for my love of math and statistics – because I certainly didn’t get that from mom! You’re so much more than “just a kid from Brooklyn” – you are my motivation, my inspiration, and my muse. Thank you for always being in my corner. To Bill (Dr. Gallo) – my mentor, my compass, and, at times, my therapist. Thank you for taking me on as a mentee and for spending countless [espresso-fueled] hours cultivating me into the researcher I am today. I never would have been able to get through this process without your guidance and sage advice. It has been an honor to work with you, and to learn from you – and learn I did! From statistical vi methodologies, manuscript construction, and proper usage of pronouns, topic sentences, and transitions to the art of oil paintings, vintage hats, and ties – I have acquired so much knowledge and grown so much in these past few years. I will carry these lessons with me throughout my lifetime. Thank you from the bottom of my heart. To Mimi (Dr. Fahs) – When I was contemplating applying to the CUNY DPH Program, I pulled up the profiles of all of the faculty members and was immediately struck by your impressive body of work. We shared a common interest in tobacco policy research which led me to reach out to you via email. I’ll never forget your response encouraging me to apply, or the warm welcome you gave me when I entered the program. I am still in disbelief that I have had the honor of working with you and the other esteemed researchers on my committee. Thank you for your guidance over these past five years. To Nancy (Dr. Sohler) – I greatly admire your fiery spirit and passion for knowledge and science, as well as your research focus on underserved populations and health disparities. Though I never had the privilege of being a student in any of your courses, I was incredibly honored when you agreed to serve on my committee and impart your invaluable feedback and unique perspective as an esteemed epidemiologist. Thank you for always making yourself available via email and Skype while you were out of the country! To Joel (Dr. Dubin) – I thank my lucky stars that Bill put us in touch a few years ago! Thank you for welcoming me to Waterloo and meeting with me to discuss SAS programming for longitudinal analyses.