Information Processing of Health Warning Messages on Cigarette Packs in Youth: An Application of Elaboration Likelihood Model CURRENT

Background The study examined the processing route of anti-smoking messages and influencing cognitive factors by using the Elaboration Likelihood Model. Methods The non-probability sample for the cross-sectional study consisted of 387 smokers in the age range of 18 to 30 years old in Tabriz, Iran. A researcher-designed questionnaire was used for the purpose of data collection. No causal inferences were drawn due to the non-experimental nature of the study. Results It was found that smokers often processed warning messages through the central route. Perceived severity, smoking abstinence self-efficacy, and psychological dependence were predictors of message processing through the central route. The results supported the conceptual model of cognitional predictors of the processing route. Conclusions To design and execute effective health warning messages to quit smoking, it is recommended to consider cognitive factors as a means to enhance critical thinking about the content of the message.

4 information processing of health warning messages on cigarette packs in a sample of Iranian youths.
The following research questions guided the study: How do smokers process health warnings on cigarette packs? What role do cognitive factors play in determining processing routes?

Study setting
The non-probability sample for the cross-sectional study consisted of 387 current smokers, ranging in age from 18 to 30 years old, who were not taking any medications for psychiatric disorder, voluntarily agreed to participate in the study, and signed a consent form. The study took place between July and November of 2018 in Tabriz, Iran. A survey instrument was used to collect the data. The content validity of the instrument was assessed by a panel of experts in health psychology and health communication.
The instrument was pilot-tested with 50 young smokers to examine its utility. The Ethics Committee of Tabriz University of Medical Sciences approved the study.

Demographics
The demographic variables included age, gender, living arrangement (with parents, personal home, dormitory), marital status (single or married), employment status (full-time, part-time, unemployed), and the highest level of education. Additionally, history of hookah use, alcohol use, drugs abuse, smoking among friends and family members, the number of cigarettes smoked per day, smoking behavior after waking up and the first bidder of cigarette smoking were measured.

Message Processing Route
For evaluating processing routes of peripheral and central, based on the ELM, we included two most influential factors of motivation and ability. The extent of motivation was determined by the attitude towards the message, personal relevance, and the need for cognition. Individuals' ability for elaboration was operationalized by distractions and knowledge. In our study, the midpoint of the sum of motivation and ability was used to categorize the processing route into the peripheral (less than 2016.65) and central (greater than 2016.65).
The attitude towards the message was measured by 12 items developed by the researchers; for example, "pictures motivated me to reduce my daily number of cigarettes smoked". Additionally, we developed 3-item scale to assess perceived relevance; for example, "in my opinion, the pictures on the cigarette packet talked about my health conditions." A 5-point Likert-type scaling (1 = strongly disagree, 5 = strongly agree) was used to measure the constructs. The need for cognition was measured by the 6-item version of Cacioppo and Petty's (1982) scale that was proposed by Lins de Holanda Coelho, Hanel, and Wolf (2018); for example, "I would prefer complex to simple problems" (16). A 5-point Likert-type scaling (1 = extremely uncharacteristic of me, 5 = extremely characteristic of me) was used. Reliability coefficients for the attitude towards the message (α = 0.92), perceived relevance (α = 0.82), and need for cognition (α = 0.71), attested to the internal consistency of the scale scores.
Additionally, ability was measured by knowledge and distractions, utilizing two scales that were developed by the research team. Specifically, an 8-item scale was used to measure the knowledge about the potential negative consequences of smoking cigarettes; for example, "smoking can cause lung cancer." Responses were coded as 0 = no/don't know or 1 = yes. A 4-item scale was used to gauge distractions, utilizing a 4-point Likert-type scaling (1 = never, 4 = always); for example, "presence of people around me caused to lose my focus on pictures and smoking outcomes." The reliability coefficients for the knowledge and distractions were 0.67 and 0.62, respectively.

Cognitive Variables
Perceived severity. To measure the seriousness of smoking risks, Harris's four-item scale of perceptions of personal risk about smoking and health was employed (17); for example, "smokers live shorter lives than non-smokers" and "smoking increases your chance of getting lung cancer." The reliability coefficient for the scale was 0.75. Sensation-Seeking. A published 8-item questionnaire was used to assess sensation-seeking behavior (Hoyle et al., 2002); for example, "I would like to explore strange places" (18). The estimated reliability coefficient was 0.82.
Psychological dependence. A four-item scale, derived from Autonomy Over Smoking scale (19) was used to measure psychological dependence; for example, "I rely on smoking to focus my attention" and "I rely on smoking to take my mind off being bored." The reliability coefficient for the scale was 0.80.
Smoking abstinence self-efficacy. A 12-item instrument (SASEQ) was used to assess self-efficacy (20); for example, ''you feel very sad, are you confident that you will not smoke?'' The reliability coefficient for this scale was 0.80.
Positive attitude toward smoking. A 9-item researcher-made instrument was used to gauge participants' attitude toward smoking; for example, "smoking makes me look attractive" and "smoking makes me feel independent." The reliability coefficient for the scale was 0.67.

Data Analysis
To analyze the data, the Statistical Package for Social Sciences (SPSS), version 23, and Mplus software, version 6, were used. Descriptive statistics, Mean (SD) and frequency (%), were used to summarize the data. Normality of all distributions was compared by examining skewness and kurtosis indices. The significance level for all analyses was set, a priori, at p ≤ 0.05. Chi-square test was used to describe the question related to participants' perception of images on cigarette packs. To compare the cognitive constructs scores in processing routes, an independent sample t-test was applied.
Applying the Mplus software, we performed structural equation modeling (SEM), with maximum likelihood estimation, to test the hypothesized model for cognitive predictors of the processing route in full sample (Model A) and gender groups (Model B). We applied χ 2 estimate with degrees of freedom as the model fit index and the root mean squared error of approximation (RMSEA) as the absolute fit index.

Results
The majority of the participants (57.40%) processed the message through the central route, of which, 80.00% were female, 73.10% lived with their families, 69.40% smoke one cigarette per day, and 72.90% reported the first cigarette offered by their friends. Whereas 40.10% who processed the message with peripheral route were male, 47.00% lived in a dormitory, 56.80% smoked more than 15 cigarettes per day, and 58.80% reported the first cigarette offered by nobody. As shown in Table 1, a series of the Chi-square Test of Independence showed a statistically significant difference in processing route by gender, residency status, smoking rate, and the first bidder of using a cigarette. As can be seen in Table 2, mean differences between the central and peripheral routes were statistically significant based on the attitudes towards smoking (favoring the peripheral route), while central route scored higher on perceived severity and psychological dependence. Sensation seeking did not distinguish between the two routes.  (4) the severity of the thirst for smoking. As shown, "frequently" was the option endorsed the most by all subjects in general and those employing the central route in particular.
Insert Table 3 about here   Table 3 Comparison The respondents were provided with five cognition reaction items: (1) thinking to quit smoking after seeing picture on cigarette packets; (2) thinking to reduce smoking after seeing pictures on cigarette packets; (3) being attracted by picture on cigarette packets; (4) being reminded of the dangers of smoking after seeing pictures on cigarette packets; and (5) being scared by seeing pictures of self. As can be seen Table 4, the majority of those who processed the messages via the peripheral route disagreed or strongly disagreed with all items. On the other hand, central route processors agreed or strongly agreed with all items. Insert Table 4 about here A series of SEM was performed to test the hypothesized model for cognitive predictors of the processing route. Model A is depicted in Fig. 1

Discussion
The young smokers in our study often processed warning messages through the central route.
According to the Elaboration Likelihood Model (ELM), message processing depends on one's motivation and ability (11); thus, if people have high motivation and ability, they process messages centrally, if not, it is probably accomplished peripherally or sensationally (21)(22)(23)(24). Since motivation depends on factors such as the attitude, need for cognition, personal relevance to the subject, and the ability of being conscious and focused (25), it can be concluded that observing images was instrumental in raising awareness/ knowledge and creating a sense of concern among the study's participants. In fact, they were thinking that these consequences were relevant to their smoking behavior. Consequently, despite the tendency to smoke, it was assumed that the study subjects processed messages through central rout and based on the ELM. Our review of the literature also showed that warning images in cigarette packages increase people's awareness about the negative impact of smoking, which eventually raises individuals' concerns about their health, thereby, provoking the attention to the importance of quitting tobacco smoking (26-32). Additionally, warning images may increase the attention and remind smokers of adverse effects of tobacco smoking.
We found that perceived severity, smoking abstinence self-efficacy, and psychological dependence were strong predictors of message processing through the central route. It is postulated that the perceived severity refers to one's belief that smoking can have serious and unpleasant consequences for his or her health (33) and numerous studies have shown that anti-tobacco warning images may increase people's fear perception and improve awareness of smokers about the side effects of tobacco use, thereby, being exposed to these messages may motivate smokers to quit smoking (26, [34][35][36][37][38]. In addition, Muñoz, Chebat, and Borges (2012) believed that graphic warnings have the potential to increase the sense of being worried about adverse consequences and influence individuals' attention and intention toward stopping cigarette smoking (39). Muñoz and his colleagues also found that these warnings messages can lead to an in-depth information processing and that focusing on graphic warning messages may provoke people to not engage in this high risk behaviors (7,39). Moreover, it seems that due to the visual clarity of illustrations about the seriousness of the damages caused by smoking, smokers may relate the health risk messages to themselves and perhaps process the message through central route, which was reported in a study about AIDS warning messages (40).
Another factor that was found to be associated with processing via central manner is psychological dependence, which postulates that an addicted person, for example, drinks or smokes to fulfill a need (41). In other words, psychological dependence arises when someone is emotionally tied to tobacco use based on her or his mental desire for it. Our findings showed that cigarette smokers who were psychologically dependent on cigarettes and were exposed to fear appeals images, they processed the scary images in a logical manner. In fact, challenges about the side effects of cigarette smoking in the mind of a smoker on one hand and psychological dependence, caused by consistent and frequent exposure to smoking and smoking-related behaviors and dependency (42), on the other hand, may explain why one does not try to quit smoking. It seems that although addicted people process the warning messages via central route, because of psychological dependence, they are unable to quit smoking or drinking. This paradox may be explained by the ELM and other theoretical frameworks, that is, why someone who processes the messages correctly via a central route, still continues its use? Thus, future studies must be conducted to provide an answer. And it seems that the ELM works better in persuasive programs, where there is no psychological dependence for quitting behavior.
Although it is assumed that high sensation-seeking people process messages through peripheral or emotional rout, we found no support for it in our study. Sensation-seeking is a personal condition; for example, wanting to experience a new thing, but without thinking about its consequences (43).This feeling develops at the age range of 10 to 15 years and reaches its peak at around of the age of 20 (44)(45)(46). Young people with high levels of sensation-seeking have a high risk-taking ability to experience physical, social, and legal risks, exhibit less protective beliefs about risky behaviors, and underestimate the severity of the risks (43,47). High sensation seekers typically do not perceive the fear of threatening situations. As a result, they do not perceive high-risk behaviors, such as, smoking, alcohol, and drug abuse as threatening behaviors (41,(48)(49)(50)(51)(52)(53)(54). It has also been reported that sensation-seeking could act as a predictor of response to a fearful condition, which may provoke a response to "fear control" that ultimately results in a defensive avoidance behavior in case of being exposed to fearful messages (55). Therefore, it seems that people with high levels of sensationseeking are not attentive to the negative consequences of smoking presented in the delivered messages. In addition, they do not try to process the messages, because they find them irrelevant to themselves. Furthermore, in accordance with the extended parallel process model, maybe these individuals enter the fear control process and reject the message with a defensive avoidance response.
Some studies have suggested that females pay more attention to warning messages than do males (56,57). However, others have found the same result in males (58,59). We found that females and males process warning messages about cigarette smoking differently but in a logical manner. For example, females are more likely to process messages through the central route than do males. The structural equation modelling of the data showed that psychological dependence predicts the processing of warning messages through central route only among men. It seems psychological dependence on cigarette smoking shifts females toward peripheral route. Thus, gender differences must be taken into consideration in designing and implementing relevant messages.

Limitations
The non-experimental study was cross-sectional; thus, no causal inferences were drawn. Due to nonprobability nature of the sampling technique, the generalizability/external validity of the study was limited to its participants. As in any survey research, providing socially acceptable responses could have been a threat to the internal validity of the results. To mitigate this possibility, respondents were assured at the start of the survey that all responses would be kept confidential.

Conclusion
Our non-probability sample of young Iranian tobacco smokers showed that they tend to process health warning messages through the central route, and pictorial health warning labels have the potential to encourage people to reduce or quit smoking with a logical approach. In addition, we suggest concerned individuals pay attention to messages that may positively impact people's attitudes toward quitting smoking by emphasizing the severity of the damage caused by smoking. Declarations

Ethics approval and consent to participate
Participants were given an information sheet on details about the research and verbal consent was collected from each participant. Verbal consent was sought to decrease the time burden on participants and increase response rates. This research and approach were reviewed and approved by the Tabriz University of Medical Sciences Institutional Review Board.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
This article is part of a Master of Science thesis in health education and promotion, which was supported and approved by Tabriz University of Medical Sciences, Tabriz, Iran. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.  Message processing route coded as 0 = peripheral route, 1 = central route.