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Background and aims Cigarette pack warning labels, especially stronger ones, stimulate quitting-related activity.This study aimed to extend understanding of impact of pack warning changes in Malaysia and Thailand,focussing on the 2009 introduction of graphic warnings in Malaysia.In particular, we aimed to: (1) compare the differences in pack warning reactions of smokers within and between these two developing countries over time, (2)examine if warning reactions predict subsequent quitting activities, and (3) examine possible wear-out effects of pack warnings in these two countries.Methods Data came from 6 waves of the International Tobacco Control Southeast Asia (the ITC SEA) Survey, a prospective cohort survey conducted among adult smokers in Malaysia and Thailand between 2005 and 2013. Between 4706 and 4422 smokers were interviewed at each survey wave. Key measures included salience of cigarette pack warnings, cognitive responses, forgoing cigarettes and avoiding warnings. The outcome measure in predictive analysis was quit attempts between survey waves.Results During the first three survey waves (2005-2008), reaction levels were significantly lower in Malaysia than in Thailand except for forgoing cigarettes at Wave l. However, at Wave 4 (shortly after the implementation of graphic warnings) the reaction levels among Malaysia smokers considerably increased from that of early waves;and for some measures the levels reached as high as that of Thailand. Compared to the early waves, the warning salience and cognitive reaction levels in Malaysia remained higher at Wave 5. But overall, in Malaysia wear-out of warnings was greater -by Wave 6, most of the reported reaction levels were no longer significantly higher than that of the baseline wave. In contrast, overall, the reaction levels of post-graphic warning waves were higher than those at the baseline wave in Thailand.For Thailand, Wave 3 warning reactions were predictive of subsequent quit attempts in bivariate analysis, and cognitive responses remained predictive in multivariate analyses, which wereconsistent with findings from the earlier waves. On the other hand, for Malaysia, Wave 3 warning reactions (to old text-only warning labels) were not predictive of subsequent quit attempts, neither in bivariate analysis, nor in multivariate analysis.In Thailand, the relations between Waves 4 and 5 warning reactions and subsequent quit attempts are essentially the same as that of Wave 3 warning reactions and quit attempts, except that forgoing at Wave 5remains independently predictive of subsequent quit attempts, as cognitive response does. The pattern of relations changed markedly for Malaysia from Wave 4: all warning reaction measures at Waves 4 and 5 becamepredictive of subsequent quit attempts in Malaysia in bivariate analysis; and in multivariate analyses, avoiding(at Wave 4) and warning salience and cognitive responses (at Wave 5) remained predictive of subsequent quitattempts, and we confirmed earlier work that this was not the case in earlier waves for Malaysia.
Conclusions In Malaysia, cigarette pack warning effectiveness in terms of increases in factors influencingquitting increased after it introduced graphic warnings (which is consistent with findings from Thailand). Wear-out of warning in Malaysia may have been greater, although our baseline may have been affected by Malaysia sfirst strong national anti-smoking campaign, something it has not subsequently matched. Consistent with previousresearch in Australia, Canada, Thailand, and elsewhere, the introduction of prominent health warnings in Malaysiaincreases smokers cognitive and micro-behaviour responses, which (especially avoidance) are found to bepredictive of quitting activities.
Conclusions In Malaysia, cigarette pack warning effectiveness in terms of increases in factors influencingquitting increased after it introduced graphic warnings (which is consistent with findings from Thailand). Wear-out of warning in Malaysia may have been greater, although our baseline may have been affected by Malaysia sfirst strong national anti-smoking campaign, something it has not subsequently matched. Consistent with previousresearch in Australia, Canada, Thailand, and elsewhere, the introduction of prominent health warnings in Malaysiaincreases smokers cognitive and micro-behaviour responses, which (especially avoidance) are found to bepredictive of quitting activities.