Harnessing hope and bolstering knowledge of how to quit: a qualitative investigation of including efficacy content in tobacco risk communication via daily SMS.

Introduction: Tobacco warning labels typically feature confronting health risk messages which aim to evoke fear to change behaviour. Evidence shows these graphic health warning labels (GHWLs) can be effective but can also lead to unintended responses, including avoidance or defensiveness. Theory suggests that targeting beliefs about the likelihood and benefits of successfully quitting may increase adaptive responses to risk information.

Methods: Participants with nil imminent quitting intentions were recruited to a randomised controlled trial (RCT) in the UK investigating the effects of receiving daily textual SMS messages targeting risk, self-efficacy, and response-efficacy beliefs on cessation behaviour. To explore their experiences receiving SMS messages during the RCT as well as their naturalistic exposure to GHWLs, we undertook a qualitative investigation conducting semi-structured interviews with 20 participants. Four main themes were generated via thematic analysis.

Results: Participants found efficacy messaging motivating, reporting increased hope for cessation. Further, these messages bolstered knowledge about cessation benefits and treatment options, which may increase treatment-related health literacy. Self-efficacy and response-efficacy messages were well-received and seen to complement each other whereas naturalistic exposure to GHWLs was associated with defensive responses and use of strategies to manage negative affect. GHWLs were seen to contribute to stigmatisation of PWS as part of a broader denormalisation of smoking.

Conclusions: GHWLs in their current form can have unintended consequences for people who smoke and can lead to defensive responses. By contrast, messages that address efficacy beliefs can increase hope, knowledge of cessation supports and motivation, thus supporting adaptive responses to smoking health risks.

Implications: Continued use of confronting GHWLs in their current form should be reconsidered. Future policy and research should investigate how efficacy content can be effectively integrated into tobacco packaging to optimise the impact of this space in targeting determinants of cessation. Efficacy content can give people who smoke hope for the future and valuable information about pathways to cessation. These benefits may have applications in other streams of health promotion such as primary care, m-health initiatives or public service announcements.