title: Exploring adolescents’ perceptions of graphic health warning labels: a cross-cultural qualitative study from the United Kingdom and the State of Qatar
Creators: name: Fanous, Nadia
Publisher: name: University of Glasgow
Year: 2020
Subjects: subject: Health communication, social marketing, fear appeal, adolescents' health, graphic health warnings, tobacco control, cross cultural.

description: Introduction: Despite the progress in tobacco control efforts, smoking remains the leading reason of preventable morbidity and mortality. Alarmingly, adolescents are the most prone to experiment with smoking and become addicted. As part of deterring and reducing smoking, the Framework Convention on Tobacco Control (FCTC) recommends the implementation of Graphic Health Warnings (GHWs) on cigarette packages. This thesis examines whether GHWs are perceived as an effective approach to reducing smoking among adolescents. It also investigates the under- researched area of whether fear appeal associated with GHWs increases stigma and how adolescents engage with and create meaning from GHWs. As yet, no research has specified the social and cultural dimensions that may be important factors to the effectiveness of GHWs among adolescents. Aim: The study takes a social marketing approach to examine the effectiveness of a public health policy, GHWs. The study follows an audience-centred approach to explore, through the lens of semiotics theory, the factors related to adolescents’ perception of GHWs in a cross-cultural context. This empirical study aims to offer an original contribution to the literature by establishing the communication relationship between context-specific and cross-cultural public health and social marketing communication in tobacco control. The study also explores adolescents’ suggestions for alternative messages and ways that could be more persuasive to change adolescents’ smoking attitudes. Method: The study followed a multi-site qualitative research method of focus groups and interviews among adolescents (13–18 years) in the UK and in Qatar. Twenty-six focus group discussions were conducted with adolescents in Qatar and a total of 9 focus groups and 6 individual interviews were conducted with adolescents in the UK. In total, 141 adolescents from both countries participated in the study. Interviews and focus groups were based on a semi-structured topic guide. The focus groups and interviews entailed an interactive methodological technique which is known as a projective technique. The technique involved three main activities for participants: ranking GHWs on a matrix of least to most persuasive for adolescents; designing their own understanding of a relevant and persuasive health message; and creating a mood board of the messages they perceive as persuasive to adolescents. Findings: The data were thematically analysed drawing on the theory of semiotics. Analysis of the data revealed three main themes and eight sub-themes. The study reveals that fear appeal is not always effective among adolescents and that it might create unintended consequences such as disengagement with the message, ethical considerations and reduced self-efficacy. The data suggest factors that are important message characteristics to account for during the development and evaluation of GHWs. Moreover, the study findings identify certain social and cultural factors that influence perceptions of GHWs. Adolescents in the study suggested alternative ways of communicating GHWs such as incorporating positively framed messages and other novel ways of communicating the anti-smoking message. Discussion: This thesis makes a theoretical contribution by adding concepts to the theory of semiotics, such as proximity and authenticity that can enhance the relevance and effectiveness of health messages. This contribution adds to the understanding of the meaning of signs and the dimensions deemed relevant in meaning creation. The study offers early insights into adolescents’ perceptions of GHWs in the Middle Eastern region and provides a comparative insight to adolescents’ perceptions in the UK. The thesis contributes original insights to the health communication and social marketing field, by raising awareness of the importance of specific message characteristics and social and cultural dimensions in influencing the perceptions of the target group. It also provides informed perspectives on the potential of positively framed messages and other novel approaches that could reduce unintended consequences. Furthermore, the study connects social marketing and health promotion principles to elevate a public health policy. By following an audience centred approach, the study explores the perspective of adolescents on GHWs and for the first time explores their suggestions for alternative messages and ways to communicate the antismoking message. Conclusion: The study highlights concepts and dimensions to be considered in tobacco control policy that could also be transferable to other health products. The study accentuates the importance of targeting and tailoring health communication through contextualised messages that engage the target audience. This perspective suggests a participatory approach of health communication messages.