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.
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.
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.
We used a 5-point Likert-type scaling (1= strongly disagree, 5 = strongly agree) to measure all abovementioned scales.
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 χ2 estimate with degrees of freedom as the model fit index and the root mean squared error of approximation (RMSEA) as the absolute fit index.