Article Finds No Effect of Graphic Posters on Purchase of Cigarettes or Smoking Cessation, But Recommends Policy Anyway

A study published online ahead of print in the journal Tobacco Control reports the result of an evaluation designed to measure the effectiveness of New York City's policy of requiring graphic anti-smoking posters at point-of-sale at all cigarette retail outlets. The requirement, which went into effect late in 2009, was intended to decrease smoking rates by encouraging smokers to quit at the point of sale.

The study consisted of two rounds of interviews conducted among customers leaving retail stores that sell cigarettes: one round at baseline (prior to the implementation of the policy) and one round nine months later.

The impact of the signs on quitting was assessed by asking recent quitters: "During this visit to the store or over the past 30 days, to what extent did these health warning signs help you to quit or stay quit?"

Participants were also asked: "“During this visit to the store, did these warning signs about smoking stop you from purchasing cigarettes when you were about to buy them?"

The major findings of the study were as follows:

1. "There was no difference across surveys in the signs helping recent quitters to stay quit (p=0.55)."

2. "Differences in signs prompting smokers not to purchase cigarettes achieved only borderline significance (15% to 8%, p=0.05)." [Note that this effect was in the wrong direction. More respondents reported being convinced not to buy cigarettes before the graphic posters than after.]

The study clearly states these findings: "The signs did not help recent quitters to stay quit or stop smokers from purchasing cigarettes at the current visit to the store."

The Rest of the Story

Despite these clear negative findings, the study instead concludes that: "Our results show that signage
implementation was associated with a doubling in the awareness of health warning signs and an 11% increase in stimulating thoughts about quitting."

Well, whoopity doo. It is no big deal that the signage increased awareness of the signage. And an 11% increase in stimulating "thoughts about quitting" is hardly consequential. The real issue is whether the policy resulted in smokers quitting and according to this study, it did not.

This is yet another example of a study whose findings are not in concordance with the reported study conclusion.

In fact, the study's final conclusion is as follows: "A policy requiring tobacco retailers to display graphic health warning signs increased awareness of health risks of smoking and stimulated thoughts about quitting smoking. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these changes and countering legal challenges from the tobacco industry."

This stated conclusion ignores the major findings of the study and instead, cherry-picks an almost trivial set of findings: that the signage increased awareness of the signage and stimulated thoughts. It ignores the fact that the study failed to find any effect of the signage on deterring the purchase of cigarettes or leading to actual quitting. In fact, the study provides no evidence whatsoever of any impact on behavior (and only a marginal impact on attitudes to begin with). This is hardly what I would call an effective policy.

Nevertheless, the article concludes that this is an effective intervention that should be pursued elsewhere.

Tellingly, the article calls for additional research "to provide further rationale" for implementing these changes. Note that the article does not call for additional research to "find out whether these changes work." Instead, the authors have apparently come to a pre-determined conclusion, and the only purpose of additional research is to confirm those conclusions and provide support for an already decided upon policy of pushing these posters, regardless of the lack of any evidence of their effectiveness.

You can see what saddens me about the current state of tobacco control science and policy. Rather than basing policy on the existing science, we instead come to a priori conclusions about what policies we want to pursue. The goal then becomes to manufacture evidence to support the pre-ordained conclusions and support the pre-ordained agenda, instead of finding out the truth of what works and what doesn't and supporting the policies that work.

The article also calls for research to counter legal challenges from the tobacco industry. Again, the purpose of the research is to manufacture evidence that the policies work so that tobacco industry challenges can be countered, rather than to find out the truth.

Also of interest is the fact that the article doesn't mention the substance of the tobacco industry challenges to New York City's policy (even to refute them). Instead, it assumes that there is no substance to the legal challenge and no legal issues to contend with. The assumption is that the only concern of public health practitioners is to defend the policy against legal challenge, not to consider whether or not the policy is consistent with the law or not.

In fact, I think there is a strong argument that this policy is unconstitutional, as it violates the First Amendment rights of retail stores by compelling speech which is designed primarily to discourage the purchase of products sold in their stores. In addition, the policy is preempted by the Federal Cigarette Labeling and Advertising Act.

But there is no discussion of these legal issues in the paper. It is assumed that they have no merit and that public health practitioners should conduct research to counter any arguments made in the opposite direction.

This is another example of how the anti-smoking movement has recently lost its science base in favor of a pre-ordained agenda. The goal is to provide evidence that supports the agenda, rather than to find out the truth, and then to develop the agenda to focus on the policies that are found to be most effective.