Kessels and Ruiter BMC Public Health 2012, 12:352 http://www.biomedcentral.com/1471-2458/12/352 smoking [11-15]. Research on appraisal, recall and level of engagement showed the largest impact when anti- tobacco television ads were presented with ‘visceral negative’ themes [16]. Particularly for starters and smo- kers intending to quit smoking, graphic warnings that are highly visible and show the negative health conse- quences of smoking were identified as successful vehi- cles for reducing smoking prevalence [8]. However, none of these studies used an experimental setup with ma- nipulation of both textual and imagery content. Further- more, most studies into the effectiveness of graphic health warnings and health communication rely on self- report measures. This runs the risk of false introspection from the participants as people may not be aware of (im- plicit) motives that drive their behaviour [17-22]. Threatening health information is often used in health messages to increase risk perceptions [23]. In contrast to the findings above, the experimental evidence regarding the effectiveness of threatening health information on measures of protection motivation and behaviour change has been mixed [24-37]. While self-relevant information usually attracts attention from the reader [38,39], a large body of experimental research suggests that people who are most at risk, have the least attention for the risk in- formation, report the least motivation to change, and subsequently react defensively to the message by means of avoidance and denial [21,22,25-27,29-31,40]. Early empirical support for the counterproductive effects of health messages was reported by Liberman and Chaiken (1992)[33]. In an experimental study, they demonstrated that coffee drinkers were less critical of information questioning the link between caffeine and fibrocystic dis- ease and more critical of information supporting the link than non-coffee drinkers [33]. Leading theoretical frameworks on the use of threaten- ing health messages, such as protection motivation theory [41] and the extended parallel process model [42] dictate that for threatening health messages to be effective indivi- duals must feel capable to perform the recommended ac- tion (i.e., high self-efficacy) [43]. For a range of health- related behaviours, self-efficacy beliefs have been identified as strong determinants of behaviour change and mainten- ance [44-48]. In addition, meta-analyses of fear appeal studies have identified self-efficacy and not risk perception as a major predictor of the intention to undertake action to protect health [45,47-51]. While self-efficacy is one of the most widely applied constructs across theories of health behaviour and presenting information that provides help to undertake action to protect health (i.e., coping in- formation) might increase levels of self-efficacy [52], cop- ing information is only rarely presented in health messages in the public domain [53]. The effects of message features and personal charac- teristics on processes of attention allocation have not Page 2 of 9 been addressed systematically in persuasion research. An exception is formed by three ERP-studies recently con- ducted by our group that investigated attention alloca- tion processes for health messages that varied in threatening content and self-relevance [21,22,39]. These studies found that individually tailored, non-threatening health communications receive more attention than non-tailored, non-threatening health communications [21,39], whereas threatening as opposed to non-threa- tening health messages are met with defensive avoidance among those for whom the health threat is personally relevant (i.e., smokers watching high threat smoking pic- tures) [22]. In the present study, we chose to use the method of eye-movement registration to measure attention alloca- tion processes for health information. Eye-movement registration enables us to measure the course of atten- tion over longer periods of time [37]. Eye movements, as important indicators of visual attention [32,54], com- promise a sequence of fixations (i.e., discrete periods of immobility of the eye) and saccades (i.e., quick jumps between fixation locations). During fixating, attention is paid to the stimulus and information is extracted, whereas during saccades vision is basically suppressed [54,55]. In eye-tracking studies the number of fixations is related to the amount of information extracted from a stimulus [54,55]. Besides the number of fixations, dwell time, the amount of time that attention spends at a loca- tion once it is deployed to that location [56], can also be used as an indicator of the amount of attention paid to a stimulus [57]. Dwell-time represents the total duration (in milliseconds) of time that was spent looking at a stimulus [37]. The primary purpose of the present study was to examine the amount of attention allocation to risk infor- mation and coping texts on cigarette packages. We sought evidence for the hypothesis that people for whom the health risk information is self-relevant will react de- fensively to this information by spending less attention – reflected in fewer fixations and less dwell time – to high risk as opposed to coping information. We expect that this differential attention response for high risk and cop- ing information will be stronger when the health text is combined with a high threat photo than with a low threat photo because of the increased overall threatening content. For non-smokers, we expect that high risk in- formation might attract more automatic attention than coping information because of the evolutionary value to detect risks (e.g. predator) over benefits (e.g., food) [58,59]. Finally, because coping information contains self-relevant information without any threat information, and self-relevant information attracts attention from the reader [39], we expect that coping texts will attract more attention from smokers than from non-smokers.