INTRODUCTION

The use of tobacco has brought great losses in both public health and economic prosperity in China. In 2013, the number of cigarettes consumed in China was equal to the combined consumption of low- and middle-income countries¹. By the end of 2015, the number of annual deaths caused by smoking in China had exceeded 1.4 million¹, and it is expected to exceed 3 million per year by 2050. Since China is a member of the Framework Convention on Tobacco Control (FCTC) of the World Health Organization (WHO), a series of measures and strategies intended to curb consumption have been formulated and implemented². However, people’s awareness of the harms of tobacco remains poor; thus, attempts to increase such awareness need to be further strengthened^3,4.

Many studies confirm that the framing-effect theory is both applicable and highly useful when researching public education for smoking reduction. The term ‘framing effect’ refers to the change of preference in a given choice caused by adjustments made in the presentation of information⁵. The framing effect was proposed by Tversky and Kahneman in 1981. Rothman and Salovey found that the positive framework was more convincing in promoting smoking cessation⁶,⁷; the negative framework did better in the disease detection behaviour^8,9. Regarding education to curb tobacco consumption, Toll et al.¹⁰ found in a clinical trial in 2008 that the smoking cessation rate was higher and the relapse interval was longer in women smokers who had received positive framing than those who had received negative framing. The results of a randomized trial in a high school showed that under the negative framework, adolescents were more concerned about elderly respiratory disease information (p<0.05)¹¹. Bresnahan et al.¹² claimed that compared to the self-targeted messages, students were more susceptible to positive messages; negative framed messages had little impact on smoking teenagers and non-smoking teenagers. Mollen and Engelen¹³ found that positive framed messages showed stronger effects on intentions to quit smoking than negative framed messages when participants were concerned about short-term outcomes.

Sindelar and O’Malley¹⁴ did a randomized field study on financial versus health motivations to quit smoking in 2009 in New Haven, USA. They designed two types of leaflets, expressing either financial or health-related benefits of smoking cessation in order to encourage readers to quit smoking. These leaflets were placed in check cashing centres, clinics, and grocery stores, which represent financial, health-related, and neutral types of locations, respectively. They then calculated the number of leaflets taken away from each location and compared the differences between each location. They used the selection of the leaflet as a proxy for interest in quitting smoking, understanding that interest is a necessary step that often serves as a proxy for both motivation and action. The results of their study indicated that in low-income areas, finance-related messages could generate more interest in quitting smoking than health-related messages. Additionally, finance-related messages could also be more powerful in commercial settings. However, the results of their study might not be generalizable across different geographical regions. Also, the study neither focused on the rate at which participants took the leaflets nor determined what factors influenced their choice to take the leaflet.

In China, research related to the reduction of tobacco consumption was always of high importance. However, no studies to date have determined whether framing effects noted in other regions may hold for China as well. Therefore, in this study we replicate for Shanghai the Sindelar and O’Malley study; specifically focusing on determining the differences in framing preferences—between finance-related and health-related—in low, middle and high income areas to prove the effect of message-framing. After presenting our results, we conclude by offering suggestions on how to improve the efficiency of education efforts designed to curb tobacco consumption in the Chinese context.

METHODS

Between June and August in 2015, tobacco control education leaflets with both finance-related and health-related framing were placed in low, middle, and high-income areas in Shanghai in three different settings—banks, hospitals, and residential areas. The two types of leaflets were placed on the exhibition shelves on-site, marked ‘Take one leaflet only’, in each setting. The number of each type of leaflet that was taken from each setting at each location was recorded. Each time a person picked up a leaflet, they were asked by the on-site research staff to fill in a questionnaire if they agreed. Every working day from June to August 2015, the research staff worked on-site during open hours (9 am to 5 pm) at the banks, hospitals, and residential areas. They asked every person who picked up a leaflet if they agreed to participate in the interview. The leaflet was allowed to be taken away even when people did not wish to fill in the questionnaire. When 500 questionnaires were filled in at a location, that location was closed.

Message framing

Two sets of leaflets were produced with visual and written messages to motivate readers to quit smoking. One of them emphasized the benefits of smoking cessation for one’s health, and the other emphasized the financial benefits. Messages were gain-framed— i.e. they focused on the positive benefits that would result over time if someone quit smoking. The health leaflets were titled ‘Quitting smoking brings health to you’, and described the health improvements over one week, one month, and one year. On the back side of the leaflets, further long-term health benefits were described. Similarly, the financial leaflets were titled ‘Quitting smoking brings wealth to you’ and described the financial gains over one week, one month, and one year. The other side of the leaflets gave further details about how much money could be saved in the long term if participants quit smoking, according to each brand’s pricing schemes.

The content of health education information on tobacco control used in this experiment is based on scientific evidence. The background color of the pages is the same warm yellow. The pictures also have obvious health or financial characteristics, reducing the interference of additional information. The content of the pages referred to Yale University’s research and refined according to science, as shown in Figures 1–4.

Figure 1

Health framing leaflet (front)

Figure 2

Health framing leaflet (back)

Figure 3

Finance framing leaflet (front)

Figure 4

Finance framing leaflet (back)

RESULTS

DISCUSSION

Overall, this study shows that the impact of educational materials designed to encourage smoking cessation is indeed influenced by the types of frames that are used to convey the message. In high-income areas, participants prefer the Health Framework, in low-income areas participants prefer the Financial Framework, and in middle-income areas, participants have no clear preference for either the Health or Financial Framework.

In health-related and neutral locations, participants were more inclined to choose messages that were within the health-related framework; in financial locations, participants were more inclined to choose those that emphasize financial gain. One possible reason why people in China are more interested in the health-related framework could be that the cost of consuming tobacco in China is relatively low. In 2015, people in Shanghai spent only about $1.08 (exchange rate 6.5 Yuan to a US$) on a cigarette pack. According to the income per capita of the year, for a pack-a-day smoker, the proportion of tobacco expense to income per capita is 5.09% (for income $58908) or 3.58% (for income $10964). Thus, the financial gain of quitting smoking is less, and people are therefore not as strongly affected by that type of motivation.

According to the different income level areas and types of location, in the high-income areas, participants tended to choose the health framework in all locations; in the low-income areas participants tended to choose the financial framework in both the health and finance-related locations and the health framework in the neutral locations. Finally, in the middle-income areas, participants were more interested in the health framework at the health-related locations and, similarly, preferred the finance framework at the finance-related locations. This is perhaps because participants in high-income areas have higher household monthly incomes, and their health concerns are more significant than financial conditions. While the financial framework details merely how much money one could save, the health framework offers more subjective or personal benefits, such as longer life, better health, and more. However, participants in low-income areas tend to be more concerned about their financial conditions than their health status. In neutral locations, the respondents’ tendency was to choose the health framework, which is different from the USA result.

In addition to the type of area and location, occupation also affected the framework preference of participants. Compared to other occupations, participants engaged in agriculture, forestry, animal husbandry and the fishery industry preferred financial information. Participants who intend to quit smoking mainly due to ‘family discouragement’ or ‘self-motivation’ preferred health information. Participants with a household per capita monthly income below 4000 Yuan were more inclined to choose the financial framework. Also, framework preference was not affected by individual factors such as gender, age, personal income, smoking status, and smoking cessation experience. According to the framing-effect theory, gender, age, and smoking status typically are only related to the Loss-Benefit Framework. However, this study is a one-way framework based on the Benefit Framework, so it is understandable that gender had no relationship with the health-financial framework.

Overall, this study has found some results that differ from the Sindelar and O’Malley study in the USA, especially regarding low-income areas and neutral locations. These divergences may be due to the differences between the two studies and differences between the two countries in tobacco prices and health education strategies. First, in the US study, grocery stores were used to represent the neutral location, but by comparison, grocery stores are more ‘financial’ compared to residential areas. This may lead participants to choose the financial framework. Second, the tobacco price in Shanghai is lower than in Connecticut, which makes participants potentially care more about information related to health rather than finance. Last, participants of low-income areas preference for health information in neutral locations might vary according to years of education about the health harms of smoking, which was the main content of tobacco control education in China.

Results notwithstanding, this study does have certain limitations. First, the study only focuses on testing the usefulness of the Health-Financial Framework for tobacco-related education messages in China, and thus no other frameworks are involved. Second, the study did not consider the situation where people may choose both types of leaflets, which means the two message framings have no significant difference in affecting people’s performance. Third, the study used only the Benefit framework and thus can offer no information regarding the Loss framework in the Chinese context. However, according to theoretical research, the Loss Framework may not have a significant effect on tobacco control information. Fourth, due to the incomplete experimental data from Yale University, it is difficult to compare differences between the two studies, in China and the United States, and the influencing factors. Finally, this study was unable to verify any potential causal associations between the frameworks used to present messages to encourage smoking cessation, any improvement in awareness of the harms of tobacco, and any consequent changes in behavior.

CONCLUSIONS

Based on the results, the following suggestions are proposed for tobacco control health education in China. First, health education information should be designed in conjunction with the framing effect theory to improve the effectiveness of the message. Different behavior objectives, framework types, information presentation and description, time and background and other factors must all be taken into account when deciding how to frame the message at hand. The individual factors of the receiver need to be fully considered in order to increase the receiver’s sense of involvement with the message. Second, considering the interactions noted between different areas and types of locations and the framework preferences, different tobacco control health education strategies should be adopted in different areas and locations to improve the efficiency of publicity. Third, targeted, personalized tobacco control health education strategies should be developed for different sociodemographic populations, e.g. pregnant women and their spouses. Furthermore, tobacco control health education can also be further analyzed from the perspective of family relations.

Research on the effect of different framing strategies on the strength and efficiency of tobacco control health education strategies in China has just begun. Future research should expand upon the present study to include other types of frameworks and different target groups, such as adolescents. Finally, although studies both in China and abroad, have shown that framing strategies do affect tobacco control health education, the mechanism by which it has this effect is still unclear.