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Icons for health effects of cigarette smoke: a test of semiotic type

Journal of Behavioral Medicine volume 40, pages 641–650 (2017)Cite this article

Abstract

We sought to identify icons to effectively communicate health harms of chemicals in cigarette smoke. Participants were a convenience sample of 701 U.S. adults. A within-subjects online experiment explored the effects of icon semiotic type: symbolic (arbitrary, most abstract), indexical, and iconic (representative, most concrete). Outcomes were perceived representation, affect toward smoking, elaboration, perceived severity, and perceived effectiveness. For not-easy-to-visualize harms of cancer and addiction, symbolic icons received the highest ratings (all p < .001). For easy-to-visualize symptoms of heart attack/stroke, indexical icons received the highest ratings (all p < .001). For easy-to-visualize harm of reproductive organ damage, the iconic image did best (all p < .001). Icon type often had a larger impact among participants with higher health literacy. Symbolic icons may be most effective for health effects not easily visualized. Iconic or indexical icons may be more effective for health effects attributable to specific body parts or symptoms.

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References

  • Andrews, J. C., Netemeyer, R. G., Kees, J., & Burton, S. (2014). How graphic visual health earnings affect young smokers’ thoughts of quitting. Journal of Marketing Research, 51, 165–183.

    Article  Google Scholar 

  • Baig, S. A., Noar, S. M., Ribisl, K. M., & Brewer, N. T. (2017). UNC perceived effectiveness scale: Psychometric properties among a large sample of adult smokers and non-smokers (Working paper)

  • Baker, R. R., Massey, E. D., & Smith, G. (2004). An overview of the effects of tobacco ingredients on smoke chemistry and toxicity. Food and Chemical Toxicology, 42, 53–83. doi:10.1016/j.fct.2004.01.001

    Article  Google Scholar 

  • Baker, D., Williams, M., Parker, R., Gazmarian, J., & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education and Counseling, 38, 33–42.

    CAS  Article  PubMed  Google Scholar 

  • Boynton, M. H., Agans, R. P., Bowling, J. M., Brewer, N. T., Sutfin, E. L., Goldstein, A. O., et al. (2016). Understanding how perceptions of tobacco constituents and the FDA relate to effective and credible tobacco risk messaging: A national phone survey of U.S. adults, 2014–2015. BMC Public Health, 16, 1–13. doi:10.1186/s12889-016-3151-5

    Article  Google Scholar 

  • Brewer, N. T., Gottlieb, S. L., Reiter, P. L., McRee, A.-L., Liddon, N., Markowitz, L., et al. (2011). Longitudinal predictors of HPV vaccine initiation among adolescent girls in a high-risk geographic area. Sexually Transmitted Diseases, 38, 197.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brewer, N. T., Hall, M. G., Noar, S. M., Parada, H., Stein-Seroussi, A., Bach, L. E., et al. (2016). Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. JAMA Internal Medicine, 176, 905–912. doi:10.1001/jamainternmed.2016.2621

    Article  PubMed  PubMed Central  Google Scholar 

  • Buhrmester, M., Kwang, T., & Gosling, S. D. (2011). Amazon’s Mechanical Turk a new source of inexpensive, yet high-quality, data? Perspectives on Psychological Science, 6, 3–5.

    Article  PubMed  Google Scholar 

  • Casler, K., Bickel, L., & Hackett, E. (2013). Separate but equal? A comparison of participants and data gathered via Amazon’s MTurk, social media, and face-to-face behavioral testing. Computers in Human Behavior, 29, 2156–2160.

    Article  Google Scholar 

  • Center for Disease Control and Prevention. (2016). Fact sheets: Smoking and tobacco use. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/

  • Centers for Disease Control and Prevention. (2013). Behavioral risk factor surveillance system questionnaire. Retrieved from https://www.cdc.gov/brfss/questionnaires/pdf-ques/2013brfss_english.pdf

  • 111th Congress of the United States of America. Family Smoking Prevention and Tobacco Control Act, Public Law 111–31, 123 Statute 1776. June 22, 2009.

  • Evans, A. T., Peters, E., Strasser, A. A., Emery, L. F., Sheerin, K. M., & Romer, D. (2015). Graphic warning labels elicit affective and thoughtful responses from smokers: Results of a randomized clinical trial. PLoS ONE, 10, e0142879. doi:10.1371/journal.pone.0142879

    Article  PubMed  PubMed Central  Google Scholar 

  • Fathelrahman, A. I., Omar, M., Awang, R., Cummings, K. M., Borland, R., & Samin, A. S. B. M. (2010). Impact of the new Malaysian cigarette pack warnings on smokers’ awareness of health risks and interest in quitting smoking. International Journal of Environmental Research and Public Health, 7, 4089–4099. doi:10.3390/ijerph7114089

    Article  PubMed  PubMed Central  Google Scholar 

  • Fowles, J., & Dybing, E. (2003). Application of toxicological risk assessment principles to the chemical constituents of cigarette smoke. Tobacco Control, 12, 424–430.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  • Garcia-Retamero, R., & Galesic, M. (2010). Who proficts from visual aids: Overcoming challenges in people’s understanding of risks. Social Science and Medicine, 70, 1019–1025. doi:10.1016/j.socscimed.2009.11.031

    Article  PubMed  Google Scholar 

  • Green, M. J., & Myers, K. R. (2010). Graphic medicine: Use of comics in medical education and patient care. British Medical Journal, 340, 574–577.

    Article  Google Scholar 

  • Hall, M. G., Ribisl, K. M., & Brewer, N. T. (2014). Smokers’ and nonsmokers’ beliefs about harmful tobacco constituents: Implications for FDA communication efforts. Nicotine & Tobacco Research, 16, 343–350. doi:10.1093/ntr/ntt158

    CAS  Article  Google Scholar 

  • Hecht, S. S. (2012). Research opportunities related to establishing standards for tobacco products under the Family Smoking Prevention and Tobacco Control Act. Nicotine & Tobacco Research, 14, 18–28. doi:10.1093/ntr/ntq216

    CAS  Article  Google Scholar 

  • Hoffmann, D., & Hoffmann, I. (2001). The changing cigarette: Chemical studies and bioassays. Smoking and Tobacco Control Monograph, 13, 159–192.

    Google Scholar 

  • Houts, P. S., Doak, C. C., Doak, L. G., & Loscalzo, M. J. (2006). The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence. Patient Education and Counseling, 61, 173–190. doi:10.1016/j.pec.2005.05.004

    Article  PubMed  Google Scholar 

  • Katz, M. G., Kripalani, S., & Weiss, B. D. (2006). Use of pictorial aids in medication instructions: A review of the literature. American Journal of Health-System Pharmacy, 63, 2391–2397.

    Article  PubMed  Google Scholar 

  • Lakoff, G., & Johnson, M. (1980). Metaphors we live by. Chicago, IL: University of Chicago Press.

    Google Scholar 

  • McCloud, S. (1993). Understanding comics: The invisible art. New York, NY: Harper Collins Publishers Inc.

    Google Scholar 

  • Meppelink, C. S., Smit, E. G., Buurman, B. M., & van Weert, J. C. (2015). Should we be afraid of simple messages? The effects of text difficulty and illustrations in people with low or high health literacy. Health Communication, 30, 1181–1189.

    Article  PubMed  Google Scholar 

  • Messaris, P. (1997). Visual persuasion: The role of images in advertising. Thousand Oaks, CA: Sage.

    Google Scholar 

  • Moracco, K. E., Morgan, J. C., Mendel, J., Teal, R., Noar, S. M., Ribisl, K. M., et al. (2016). “My first thought was croutons”: Perceptions of cigarettes and cigarette smoke constituents among adult smokers and nonsmokers. Nicotine & Tobacco Research, 18, 1566–1574.

    Article  Google Scholar 

  • Moriarty, S. (2002). The symbiotics of semiotics and visual communication. Journal of Visual Literacy, 22, 19–28.

    Article  Google Scholar 

  • Nakamura, C., & Zeng-Treitler, Q. (2012). A taxonomy of representation strategies in iconic communication. International Journal of Human-Computer Studies, 70, 535–551.

    Article  PubMed  PubMed Central  Google Scholar 

  • Palmer-Wackerly, A. L., & Krieger, J. L. (2015). Dancing around infertility: The use of metaphors in a complex medical situation. Health Communication, 30, 612–623. doi:10.1080/10410236.2014.888386

    Article  PubMed  Google Scholar 

  • Peirce, C. S. (1991). Peirce on signs: Writing on semiotic. Chapel Hill, NC: University of North Carolina Press.

    Google Scholar 

  • Peters, E., Västfjäll, D., Slovic, P., Mertz, C., Mazzocco, K., & Dickert, S. (2006). Numeracy and decision making. Psychological Science, 17, 407–413.

    Article  PubMed  Google Scholar 

  • Rodgman, A., & Perfetti, T. A. (2013). The chemical components of tobacco and tobacco smoke. Boca Raton, FL: CRC Press.

    Book  Google Scholar 

  • Sopory, P. (2005). Metaphor in formative evaluation and message design: An application to relationships and alcohol use. Health Communication, 17, 149–172.

    Article  PubMed  Google Scholar 

  • Stevens, J. P. (2007). Intermediate statistics: A modern approach (3rd ed.). New York, NY: Routledge.

    Google Scholar 

  • Talhout, R., Schulz, T., Florek, E., Van Benthem, J., Wester, P., & Opperhuizen, A. (2011). Hazardous compounds in tobacco smoke. International Journal of Environ Research and Public Health, 8, 613–628. doi:10.3390/ijerph8020613

    Article  Google Scholar 

  • United States Department of Health Human Services. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf

  • United States Department of Health and Human Services. (2016). Nicotine addiction and your health. Retrieved from http://betobaccofree.hhs.gov/health-effects/nicotine-health/

  • United States Food and Drug Administration. (2012). Harmful and potentially harmful constituents in tobacco products and tobacco smoke: Established list. Retrieved from http://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/ucm297786.htm

  • Wayne, G. F., & Carpenter, C. M. (2009). Tobacco industry manipulation of nicotine dosing Nicotine. Psychopharmacology (Berl), 192, 457–485.

    CAS  Google Scholar 

  • Yu, B., Willis, M., Sun, P., & Wang, J. (2013). Crowdsourcing participatory evaluation of medical pictograms using Amazon Mechanical Turk. Journal of Medical Internet Research, 15, e108.

    Article  PubMed  PubMed Central  Google Scholar 

  • Zikmund-Fisher, B. J., Witteman, H. O., Dickson, M., Fuhrel-Forbis, A., Kahn, V. C., Exe, N. L., et al. (2014). Blocks, ovals, or people? Icon type affects risk perceptions and recall of pictographs. Medical Decision Making, 34, 443–453. doi:10.1177/0272989X13511706

    Article  PubMed  Google Scholar 

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Acknowledgements

Research reported in this publication was supported by Grant Number P50CA180907-03S1 from the National Cancer Institute and FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

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Affiliations

  1. School of Media and Journalism, University of North Carolina at Chapel Hill, 384 Carroll Hall (CB 3365), Chapel Hill, NC, 27599-3365, USA

    Allison J. Lazard

  2. Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA

    Annie Schmidt, M. Justin Byron, Marcella H. Boynton & Noel T. Brewer

  3. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA

    Huyen Vu, M. Justin Byron, Marcella H. Boynton & Noel T. Brewer

  4. Department of Psychology, The Ohio State University, Columbus, OH, USA

    Ellen Peters

Authors
  1. Allison J. Lazard
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  2. Annie Schmidt
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  3. Huyen Vu
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  4. M. Justin Byron
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  5. Ellen Peters
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  6. Marcella H. Boynton
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  7. Noel T. Brewer
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Correspondence to Allison J. Lazard.

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Conflict of interest

Allison J. Lazard, Annie Schmidt, Huyen Vu, M. Justin Byron, Ellen Peters, Marcella H. Boynton, and Noel T. Brewer declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants for being included in the study.

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Lazard, A.J., Schmidt, A., Vu, H. et al. Icons for health effects of cigarette smoke: a test of semiotic type. J Behav Med 40, 641–650 (2017). https://doi.org/10.1007/s10865-017-9833-3

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  • DOI: https://doi.org/10.1007/s10865-017-9833-3

Keywords

  • Icons
  • Pictograph
  • Warning
  • Cigarette
  • Health effects