Cigarette package inserts can promote efficacy beliefs and sustained smoking cessation attempts: A longitudinal assessment of an innovative policy in Canada

Background: In June 2012, Canada implemented new pictorial warnings on cigarette packages, along with package inserts with messages to promote response efficacy (i.e., perceived quitting benefits) and self-efficacy (i.e., confidence to quit). This study assessed smokers' attention toward warnings and inserts and its relationship with efficacy beliefs, risk perceptions and cessation at follow-up. Methods: Data were analyzed in 2015 from a prospective online consumer panel of adult Canadian smokers surveyed every four months between September 2012 and September 2014. Generalized Estimating Equation models were estimated to assess associations between reading inserts, reading warnings and efficacy beliefs (self-efficacy, response efficacy), risk perceptions, quit attempts of any length, and sustained quit attempts (i.e., 30 days or more) at follow-up. Models adjusted for socio-demographics, smoking-related variables, and time-in-sample effects. Results: Over the study period, reading warnings significantly decreased (p < 0.0001) while reading inserts increased (p = 0.004). More frequent reading of warnings was associated independently with stronger response efficacy (B_{often/very often vs never} = 0.28, 95% CI: 0.11-0.46) and risk perceptions at follow-up (B_{often/very often vs never} = 0.31, 95% CI: 0.06-0.56). More frequent reading of inserts was associated independently with stronger self-efficacy to quit at follow-up (B_{twice or more vs none} = 0.30, 95% CI: 0.14-0.47), quit attempts (OR_{twice or more vs none} = 1.68, 95% CI: 1.28-2.19), and sustained quit attempts (OR_{twice or more vs none} = 1.48, 95% CI: 1.01-2.17). Conclusions: More frequent reading of inserts was associated with self-efficacy to quit, quit attempts, and sustained quitting at follow-up, suggesting that inserts complement pictorial HWLs.