Information Processing of Health Warning Messages on Cigarette Packs Among Young Iranian Smokers: An Application of Elaboration Likelihood Model

Background: One of the major smoking prevention strategies has been to educate the public and increase people’s awareness, using health warning messages. However, many young people continue smoking without paying attention to health risk messages on cigarette packets in Iran. Hence, this study was conducted to examine the processing route of anti-smoking messages and inuencing 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-ecacy, 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.

to health risk messages. Therefore, it may be concluded that message processing is different for young people than older ones. There is a lack of evidence in Iran about how the youth processes the tobaccorelated risk messages. The primary purpose of the study was to evaluate the 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?

Subject Selection
The cross-sectional was conducted between July and November of 2018 in Tabriz, Iran with 387 current smokers. To recruit the participants, 10 parks and coffee shops in Tabriz's 10 districts were randomly selected. The sample consisted of the youth who ranged in age from 18 to 30 years, reported being smokers, were not taking any medications for psychiatric disorder, voluntarily agreed to participate in the study, and signed the consent, representing a non-random sample. Data were collected through a selfadministered questionnaire. Cigarette packs with health warning messages, which had been prepared by the research team, were presented to the participants before completing the questionnaires. The Ethics Committee of Tabriz University of Medical Sciences had approved the study.

Instrumentation
A panel of Seven (7) health psychologists and eight (8) health education and promotion experts examined the content validity of the instrument by rating each questionnaire item for relevance, clarity, representativeness, and essentiality. The means of the content validity index (CVI) and the content validity ratio (CVR) were 0.87 and 0.95, respectively, attesting to the content validity of the instrument.
The instrument was pilot-tested with 50 young smokers to examine its utility.

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 rst 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 in uential factors of "motivation" and "ability". The extent of motivation was determined by the attitude towards the message, personal relevance, and the need for cognition. Additionally, 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) or 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 3item scale to assess perceived relevance; for example, "in my opinion, the pictures on the cigarette packet talked about my health conditions." 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 et al. (2018) (24,25); for example, "I would prefer complex to simple problems". A 5-point Likert-type scaling (1 = extremely uncharacteristic of me, 5 = extremely characteristic of me) was used. Reliability coe cients 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. Speci cally, 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 coe cients 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 (26); for example, "smokers live shorter lives than non-smokers" and "smoking increases your chance of getting lung cancer". The reliability coe cient for the scale was 0.75. Sensation-Seeking. A published 8-item questionnaire was used to assess sensation-seeking behavior (27); for example, "I would like to explore strange places". The estimated reliability coe cient was 0.82.
Psychological dependence. A four-item scale, derived from Autonomy Over Smoking scale (28) 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 coe cient for the scale was 0.80.
Smoking abstinence self-e cacy. A 12-item instrument (SASEQ) was used to assess self-e cacy (29); for example, ''you feel very sad, are you con dent that you will not smoke?'' The reliability coe cient 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 coe cient for the scale was 0.67. Cognition reaction. A 5-item researcher-made scale, which was based on a published study (29) was used to gauge the cognitive response that participants felt after seeing the images; for example, "I felt scared after seeing my pictures." The reliability coe cient for the scale was 0.76.
With the exception of ability, we used a 5-point Likert-type scaling (1 = the lowest, 5 = the highest) to measure the abovementioned scales. For the purpose of the SEM, all were standardized, ranging from 0 to 100.

Health Warning Messages on Cigarette Packs
The research team developed four (4) health warning messages to stick on cigarette packs that were pictorial in nature, because they are known to be more effective than are the text warnings (29). Given that health warning messages that emphasize the physical consequences of a threat are helpful in informing and encouraging people to engage in preventive health behavior (30), we used images related to smoking-related (e.g., cancers of the respiratory system, mouth, and teeth, Buerger's disease).

Data Analysis
To analyze the data, the Statistical Package for the Social Sciences (SPSS), version 23, and Mplus software, version 6, were used. Descriptive statistics, Mean (SD) and frequency (%), were used to summarize the data. The respondents' responses to the questionnaire items were used to measure each scale score. The normality of all distributions was examined by skew and kurtosis indices. A series of Chisquare Test of Independence was performed to examine the simple associations between the processing route and demographic characteristics. To compare the cognitive constructs scores in processing routes, a series of independent sample t-test was applied. The signi cance level for all analyses was set, a priori, at 0.05.
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). The SEM included model speci cation, identi cation, estimation, testing, and modi cation. The rst step focused on the conceptual model regarding the hypotheses. The second step consisted of the model t process, wherein the number of input and output parameters were suitably chosen. The maximum likelihood estimation was performed in the third step. The t indices were assessed in the fourth step. In the fth step, the modi cation indices were used to modify the model. Model t measures were attained to judge how well the proposed model captured the covariances between all measures. Since the quality of tted models is in uenced by the sample size, multiple model t indices were estimated, which were as follows: χ2 (p > 0.05), χ2/degrees of freedom < 5, the Root Mean Square Error of Approximation (RMSEA ≤ 0.08), the Standardized Root Mean Square Residual (SRMR ≤ 0.05), the Comparative Fit Index (CFI ≥ 0.90), and Tucker-Lewis index (TLI ≥ 0.90) (31).

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 rst 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 rst cigarette offered by nobody. As shown in Table 1, a series of the Chi-square Test of Independence showed a statistically signi cant difference in processing route by gender, residency status, smoking rate, and the rst bidder of using a cigarette.
As can be seen in Table 2, mean differences between the central and peripheral routes were statistically signi cant based on the positive attitudes towards smoking (favoring the peripheral route), while central route scored higher on smoking abstinence self-e cacy, perceived severity, and psychological dependence. Sensation seeking did not distinguish between the two routes.
The respondents were provided with four distraction items: (1) presence of other people at their side distracting their attention to warning images; (2) not paying attention to risk message images on cigarette packs when doing other things; (3) becoming worried by the pictures on the cigarette packets; and (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.
The respondents were provided with ve 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.
A series of SEM was performed to test the hypothesized model for cognitive predictors of the processing route. Model A is depicted in Figure1 and shows the predictors among young smokers. The measurement model resulted in a good model t (χ 2 = 71.78, n = 387, df = 5, p < 0.05, CFI = 1.00, TLI = 1.00, RMSEA = 0.00, CI: 0.00, 0.05). The direct associations between self-e cacy, perceived severity, psychological dependence as predictor of the central route were statistically signi cant. The association between sensation seeking and the had central route was not statistically signi cant. Moreover, results indicated a statistically signi cant direct relation between attitude toward smoking and peripheral route. The following prediction equation was obtained: Message Processing Route = 4.398 -0.001 × Attitude + 0.056 × Self-e cacy + 0.113 × Perceived Severity + 0.010 × Sensation Seeking + 0.055 × Psychological Dependence, in which, 1-unit increase in attitude results in 0.001 decrease in message processing route. Additionally, 1-unit increase in self-e cacy, perceived severity, sensation seeing, and psychological dependence results in 0.056, 0.113, 0.010, and 0.055 increase in message processing route, respectively.
Next, we evaluated Model B for males and females separately and found that the conceptual model obtained from testing the goodness of t causal structure of the hypothesized model t the data well (χ2 = 0.00, n = 387, df = 0, p < 0.05, CFI = 1.00, TLI = 1.00, RMSEA = 0.00 (CI: 0.00, 0.05). Among males and with respect to central route, the negative association with the attitude toward smoking and positive relations with self-e cacy, perceived severity, and psychological dependence were statistically signi cant. Among females, the positive associations between self-e cacy and perceived severity as predictors of the central route were statistically signi cant. Results are depicted in Figures 2 and 3.
The prediction equation for the males, Message Processing Route = 4.145 -0.002 × Attitude + 0.058 × Self-e cacy + 0.084 × Perceived Severity + 0.019 × Sensation Seeking + 0.061 × Psychological Dependence, shows that 1-unit increase in attitude results in 0.002 decrease in message processing route, while 1-unit increase in self-e cacy, perceived severity, sensation seeking, and psychological dependence results in 0.058, 0.084, 0.019, and 0.061 increase in message processing route, respectively.
The prediction equation for the females, Message Processing Route = 4.145 -0.001 × Attitude + 0.052 × Self-e cacy + 0.101 × Perceived Severity -0.008 × Sensation Seeking + 0.056 × Psychological Dependence, shows that 1-unit increase in attitude and sensation seeking results in 0.001 and 0.008 decrease in message processing route, respectively, and 1-unit increase in self-e cacy, perceived severity, and psychological dependence results in 0.052, 0.101, and 0.056 increase in message processing route, respectively.

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 (32)(33)(34)(35). 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 (36), 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 (37)(38)(39)(40)(41)(42)(43). Additionally, warning images may increase the attention and remind smokers of adverse effects of tobacco smoking.
We found that perceived severity, smoking abstinence self-e cacy, 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 (44) 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 (37,(45)(46)(47)(48)(49). In addition, Muñoz, Chebat, and Borges (2013) believed that graphic warnings have the potential to increase the sense of being worried about adverse consequences and in uence individuals' attention and intention toward stopping cigarette smoking (50). 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 (7,50). 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 (16).
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 ful ll a need (51). In other words, psychological dependence arises when someone is emotionally tied to tobacco use based on her or his mental desire for it. Our ndings 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 (52), 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 (53).This feeling develops at the age range of 10 to 15 years and reaches its peak at around of the age of 20 (54)(55)(56). 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 (53,57). 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 (51,(58)(59)(60)(61)(62)(63)(64) . 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 (65) .
Therefore, it seems that people with high levels of sensation-seeking 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 nd 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 (66,67). However, others have found the same result in males (68,69). 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.
Repetition of message could be one of the factors which is related to the ability to think and enables more people to think in a logical manner. Hence in case of presenting a strong argument, repetition of message probably leads to more change in beliefs. Additionally, quality of argument may have an in uential role in interventional studies conducted within the framework of the Elaboration Likelihood Model (70).
Moreover, it is postulated that individuals distinguish strong and weak arguments only if they are able to process the message in a systematic manner. In other words, reading a message containing strong arguments will be accepted easily in comparison to messages containing weak arguments. As a result, if someone does not process the message systematically, it may not be able to distinguish strong and weak arguments; thus, argument would be unquali ed. Based on this reasoning, the presence or absence of an effect of argument quality on acceptance of the message, indicates how people process the message systematically or not (11,71).

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 con dential.

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. It seems that people who are addicted to smoking are insightful and understand the side effects of tobacco use but because of their dependency on nicotine, they cannot cease it. In other words, despite understanding the consequences of tobacco use and process the message through the central route, they cannot cease it. However, non-smokers probably process the health warning messages through a different route. Therefore, it is necessary to consider the quality of the arguments, the individuals' awareness of the consequences of smoking, and the repetition of the message in designing the messages in order to change people's attitudes towards smoking. Health o cials should pay special attention to the demographic characteristics of smokers in designing health warning messages related to smoking to increase their effectiveness. 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
The authors declare that they have no con ict of interest.

Funding
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.
Author contributions FSH, SP, and HA designed the study. FSH collected the survey data. FSH, SP, MAJ, and HA analyzed the data. FSH, SP, MAJ, and HA were major contributors in writing the manuscript. KK edited the manuscript. All authors read and approved the nal manuscript.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. ElectronicSupplementaryMaterial.doc