"You're made to feel like a dirty filthy smoker when you're not, cigar smoking is another thing all together." Responses of Australian cigar and cigarillo smokers to plain packaging

Objective To explore experiences of cigar and cigarillo smokers under Australian laws requiring plain packaging (PP) and strengthened graphic health warnings (GHWs). Methods In February/March 2014, we conducted: in-depth interviews with 10 regular premium cigar smokers; two focus groups with occasional premium cigar and premium cigarillo smokers (n=14); four focus groups with non-premium cigarillo smokers (n=28); and a national online survey of cigar and/or cigarillo smokers (n=268). Results Premium cigar smokers had limited exposure to PP, with many purchasing fully branded cigars in boxes duty free or online and singles in non-compliant packaging. Those who were exposed noticed and were concerned by the warnings, tried to avoid them and felt more like 'dirty smokers'. Changes in perceived taste, harm and value were minimal for experienced premium cigar smokers. Occasional premium cigar and premium cigarillo smokers with higher PP exposure (gained by purchasing boxes rather than singles) perceived cigar/ package appeal and value had declined and noticed the GHWs. Non-premium cigarillo smokers reported high PP exposure, reduced perceived appeal, quality, taste, enjoyment and value, somewhat increased perceived harm, greater noticeability of GHWs and concealment of packs and more contemplation of quitting. Online survey participants reported increased noticeability of GHWs (33%), decreased appeal of packaging (53%) and reduced consumption of cigars (42%) and cigarillos (44%) since PP implementation. Conclusions Non-premium cigarillo smokers appear to have been most exposed and influenced by PP, with cigar smokers less so, especially regular premium cigar smokers who have maintained access to fully branded products.Caroline L Miller, Kerry A Ettridge, Melanie A Wakefiel

Understanding variation in men’s help-seeking for cancer symptoms: a semi-structured interview study

Men appear more likely to delay seeking medical advice for cancer symptoms, resulting in later stage at diagnosis and poorer health outcomes. Limited research has investigated variation in men’s experiences of and responses to cancer symptoms. This study examined the psychosocial aspects of men’s help-seeking for cancer symptoms, as well as potential variation across men residing in urban and rural Australia. Semi-structured interviews were conducted with men recently diagnosed with cancer (n=13). Participants’ partners (n=8) were recruited to enable data triangulation. Interview schedules addressed participants’ pathway to cancer treatment, cancer knowledge, masculinity, and rural living. A theoretical thematic analysis approach was used. Medical help-seeking behaviour was similar for participants residing in urban and rural areas. Five key themes and one sub-theme were identified, including: symptom factors, traditional masculine norms (sub-theme: women’s health-related responsibilities), level of concern, conflicting responsibilities and access, and trust in medical professionals. Participants from rural Australia experienced greater access difficulties and noted optimism regarding symptoms. Results highlight important within-gender differences in the psychosocial barriers to help-seeking for cancer symptoms. Future research should further explore variation between men and test the predictive strength of factors

A randomised experimental study comparing perceptions of two energy drink health warning labels.

Issue addressed: Consumption of energy drinks is a public health concern, particularly in adolescents and young adults. This study explored energy drink consumers' reactions to an energy drink-specific warning label (risk of cardiac effects) and a more general sugary drink warning label (risk of obesity). Methods: An online experimental study randomly allocated Australian energy drink consumers aged 18-39 years (N = 435) to view one of two label conditions (cardiac effects or obesity). Participants were assessed on: intention to reduce energy drink consumption, perceived health threat, perceived label effectiveness and policy support for energy drink warning labels. Results: Mean intentions to reduce consumption scores were similar across the two label conditions (Mobesity = 2.5, Mcardiac = 2.6) overall; and were higher for the cardiac label (compared to obesity label) for some subgroups: females (Mobesity = 2.3, Mcardiac = 2.8; p = .037), older (25-39 years; Mobesity = 2.4, Mcardiac = 2.8; p = .016); and higher education level (Mobesity = 1.9, Mcardiac = 2.7; p = .004). While perceived health threat measures were higher for obesity than cardiac effects, perceived label effectiveness measures of ‘believable’ and ‘relevant to me’ were higher for the cardiac label than the obesity label (believable: 71.0% vs 56.1%; relevant: 42.5% vs 29.4%). Participants who viewed the cardiac label were more likely to support policy than those shown the obesity label (OR = 1.6, 95%CI [1.1, 2.3], p = .02). Conclusions: Health effect warnings labels were perceived by energy drink consumers to be impactful and are supported. Labels with energy drink-specific health effects may offer additional benefit. So what?: Policy makers can feel confident that warning labels on energy drinks will confer public health benefit.Joanna Caruso, Caroline Miller, Deborah Turnbull, Kerry Ettridg

Predicting men’s intentions to seek help for cancer symptoms: a comparison of the Theory of Planned Behaviour and the Health Belief Model

Objective: Targeted behavioural interventions are needed to address psychosocial factors leading to slower help-seeking for cancer symptoms among men. This study compared the variance in men’s help-seeking intentions explained by the Theory of Planned Behaviour and Health Belief Model. Method: A cross-sectional survey of 127 men was conducted, testing symptom knowledge and theory-derived constructs from the Theory of Planned Behaviour (attitudes, perceived norms, perceived behavioural control) and Health Belief Model (susceptibility, severity, benefits, barriers). The outcome variable was intention to seek help for cancer symptoms. Separate and combined hierarchical regressions tested the relative predictive power of the two models, potential overlap in variance explained, and the most salient constructs within the models. Results: Separate regressions (controlling for age and symptom knowledge) showed each model explained 10–12% variance in men’s help-seeking intentions over and above the adjusted variables. The combined regression indicated symptom knowledge, perceived benefits, and perceived behavioural control were significant predictors of men’s intentions (35% total variance explained). Conclusions: The Theory of Planned Behaviour and Health Belief Model may not be optimal models for explaining men’s help-seeking intentions for cancer symptoms, however, select constructs are important correlates. Future interventions may usefully target symptom knowledge, health beliefs, and control beliefs

Patient-reported functional outcome measures and treatment choice for prostate cancer

Background The aim of this study was to describe changes in patient-reported functional outcome measures (PROMs) comparing pre-treatment and 12 months after radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy and active surveillance (AS). Methods Men enrolled from 2010 to 2019 in the South Australian Prostate Cancer Clinical Outcomes Collaborative registry a prospective clinical registry were studied. Urinary, bowel, and sexual functions were measured using Expanded Prostate Cancer Index Composite (EPIC-26) at baseline and 12 months post-treatment. Higher scores on the EPIC-26 indicate better function. Multivariable regression models were applied to compare differences in function and extent of bother by treatment. Results Of the 4926 eligible men, 57.0% underwent RP, 20.5% EBRT, 7.0% brachytherapy and 15.5% AS. While baseline urinary and bowel function varied little across treatment groups, sexual function differed greatly (adjusted mean scores: RP = 56.3, EBRT = 45.8, brachytherapy = 61.4, AS = 52.8; p < 0.001). Post-treatment urinary continence and sexual function declined in all treatment groups, with the greatest decline for sexual function after RP (adjusted mean score change − 28.9). After adjustment for baseline differences, post-treatment sexual function scores after EBRT (6.4; 95%CI, 0.9–12.0) and brachytherapy (17.4; 95%CI, 9.4–25.5) were higher than after RP. Likewise, urinary continence after EBRT (13.6; 95%CI, 9.0-18.2), brachytherapy (10.6; 95%CI, 3.9–17.3) and AS (10.6; 95%CI, 5.9–15.3) were higher than after RP. Conversely, EBRT was associated with lower bowel function (− 7.9; 95%CI, − 12.4 to − 3.5) than RP. EBRT and AS were associated with lower odds of sexual bother (OR 0.51; 95%CI, 0.29–0.89 and OR 0.60; 95%CI, 0.38–0.96, respectively), and EBRT with higher odds of bowel bother (OR 2.01; 95%CI, 1.23–3.29) compared with RP. Conclusion The four common treatment approaches for prostate cancer were associated with different patterns of patient-reported functional outcomes, both pre- and 12 months post-treatment. However, after adjustment, RP was associated with a greater decline in urinary continence and sexual function than other treatments. This study underscores the importance of collecting baseline PROMs to interpret post-treatment functional outcomes.Tenaw Tiruye, Michael O, Callaghan, Kim Moretti, Alex Jay, Braden Higgs, Kerry Santoro, Terry Boyle, Kerry Ettridge, and Kerri Beckman

"You can't just eat 16 teaspoons of sugar so why would you drink 16 teaspoons' worth of sugar?": a qualitative study of young adults' reactions to sugary drink warning labels

Background: Several jurisdictions have introduced nutrient warning front of pack (FoP) labels in an effort to curb consumption of ultra-processed foods and beverages high in free sugars (sugars added to foods and beverages, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates). This study aimed to explore consumer understanding and perceptions of FoP warning labels that convey different nutritional and health information messages regarding the consumption of sugary drinks. Methods: Sixteen focus groups were held with 4–8 young adults per group (aged 18–24; n = 105 participants in total) stratified by education level, location (rural centres, large cities) and gender (males, females) to ensure diversity. Labels shown to participants during group discussions included text warning labels of health effects, exercise equivalents, calorie/kilojoule information and sugar content as a “high in” label and as teaspoons (text and pictograms). Thematic analysis was undertaken. Results: Four themes were identified related to participants’ perceived effectiveness of labels: the extent to which labels were perceived to be useful, relevant and credible; the extent to which a label elicited shock or disgust (perceived aversiveness); the extent to which the label message was resistant to self-exemption; and participants’ perceived potential of the label to reduce purchasing and consumption behaviour. Across all four themes, labels communicating the number of teaspoons of sugar in a sugary drink (whether by text or pictogram) were perceived as the most impactful, resistant to self-exemption and to have the greatest potential to reduce consumption, with enhanced reactions to the pictogram label. Labels depicting health effects, exercise equivalents, calorie/kilojoule information or a general ‘high in sugar’ warning were perceived by consumers to be less effective in one or more themes. Conclusions: Labels conveying the amount of sugar in a beverage in teaspoons were perceived as highly factual, relatable and interpretable, and as having the greatest potential to impact consumption attitudes and intentions. Further quantitative studies are required to compare the potential effectiveness of the teaspoons of sugar labels in reducing purchasing and consumption behaviour than other alternative warning labels, such as health effects or “high in” sugar labels.C Miller, K Wright, J Dono, S Pettigrew, M Wakefield, J Coveney, G Wittert, D Roder, S Durkin, J Martin, and K Ettridg

Consumption of sugar-sweetened beverages, Jjuice, artificially-sweetened soda and bottled water: an Australian population study

Reducing consumption of free sugars, such as those found in high concentrations in manufactured products such as sugar-sweetened beverages (SSBs) and 100% fruit juices, is a global public health priority. This study aimed to measure prevalence of widely available pre-packaged non-alcoholic water-based beverages (carbonated sodas, sports drinks, energy drinks, artificially-sweetened sodas, fruit juices (any type), and bottled water) and to comprehensively examine behavioral, environmental, current health, and demographic correlates of consumption. A cross-sectional, nationally-representative population survey of 3430 Australian adults (18+ years) was conducted using computer-assisted telephone (mobile and landline) interviewing. Past week prevalence of pre-packaged drinks containing free sugar was 47.3%; daily prevalence was 13.6%. Of all the pre-packaged drinks assessed, consumption of fruit juices (any type) was the most prevalent (38.8%), followed by bottled water (37.4%), soda (28.9%), artificially-sweetened soda (18.1%), sports drinks (8.1%), and energy drinks (4.2%). Higher soda consumption was associated with males, younger age, socio-economic disadvantage, frequent takeaway food consumption, availability of soda in the home, obesity, and a diagnosis of heart disease or depression. A diagnosis of Type 2 Diabetes was associated with increased likelihood of consuming artificially-sweetened sodas and decreased likelihood of consuming sugar-sweetened soda. SSB consumption is prevalent in Australia, especially among young adults and males, foreshadowing continued population weight gain and high burdens of chronic disease. To reduce consumption, Australia must take a comprehensive approach, incorporating policy reform, effective community education, and active promotion of water.Caroline Miller, Kerry Ettridge, Melanie Wakefield, Simone Pettigrew, John Coveney ... Gary Wittert ... et al

Nothing beats taste or convenience: a national survey of where and why people buy sugary drinks in Australia

First published: 08 June 2020OBJECTIVE: There is limited knowledge of what influences sugary drink purchasing decisions in the Australian population. This study aimed to identify the most common locations and reasons across different demographic groups for purchasing sugary drinks in Australia. METHODS: A total of 891 respondents (who purchased sugary drinks for personal consumption at least occasionally) from a broader national population telephone survey of Australian adults conducted in 2017 (n=3,430) were included in the analysis. RESULTS: 'Taste' was a ubiquitous reason for purchase (94%) and the majority also agreed with 'easily available' (76%). Males, younger people and people of lower socioeconomic status (SES) were significantly more likely to agree that sugary drinks were 'cheap' and 'better value than water'. Furthermore, males and younger people were more likely to report buying sugary drinks because they were 'part of a meal deal'. The most common purchase locations were supermarkets (56%), followed by convenience stores (19%) and food or entertainment venues (17%). CONCLUSION: Taste is paramount in decisions to purchase sugary drinks, and widespread availability and value for money support consumption. Implications for public health: Policies and interventions targeting point-of-sale sugary drink purchasing decisions among the most 'at risk' consumers are warranted.Joanne Dono, Kerry Ettridge, Melanie Wakefield, Simone Pettigrew ... David Roder ... Caroline Miller ... et al

Associations between risk attributes, "control" and "dread", with perceptions of importance of cancer risk factors

Special Issue: Hunter Cancer Research Alliance Annual Symposium 2014Background: Previous studies indicate lay perceptions of the importance of lifestyle factors in cancer risk are not necessarily consistent with epidemiological evidence. Providing insight into the factors associated with these perceptions may inform future cancer prevention strategies. Aim: This study explored whether differences in perceptions of importance of a range of factors in cancer risk could be explained by different factor attributes, with a specific focus on "Control" and "Dread" which feature prominently in the risk perception literature. Methods: A sample of convenience (n = 168; 17-57 years) comprised of students (n = 130) and non-academic staff (n = 38) from two South Australian Universities completed an online survey assessing perceived importance of 12 factors in cancer risk and six attributes for each risk factor (control, voluntariness, knowledge, dread, catastrophic potential and severity of consequences; assessed by psychometric paradigm scales-modified; Fischhoff et al., 1978). Results: Cigarette smoking was most commonly rated as very or extremely important in cancer risk (89%), followed by sun exposure, family history, pesticides and overweight (48-67%). Less than 40% rated other factors (e.g., alcohol, exercise, stress) as very or extremely important. Principal components analyses confirmed two attribute factors: "Control" (perceptions of controllability and voluntariness) and "Dread" (knowledge, dread and perceptions of severity of consequences and catastrophic potential). Logistic regression analyses, adjusted for gender, staff/student status, age and language spoken at home, indicated that "Dread" was positively associated with perceived importance for all risk factors (p < .001), and "Control" was positively associated with five risk factors (sun, diet, mobile phones, exercise and overweight; p < .01). Conclusions: The degree of "Dread" associated with risk factors, and to some extent "Control" contributed to explaining variation in perceptions of importance of a number of cancer risk factors. However, the variation explained differed considerably between risk factors, indicating that other potential influencing factors should be explored in future studiesKerry Ettridge, Natalie Hunt, Carlene Wilso

The relationship between sun protection policy and associated practices in a national sample of early childhood services in Australia

Limiting exposure to sunlight during childhood can significantly reduce the risk of skin cancer. This was the first national study to assess the sun protection policies and practices of early childhood services across Australia. It also examined the key predictors of services' sun protection practices. In 2007, 1017 respondents completed a self-administered survey about the sun protection policies and practices in their early childhood service (response rate of 59%). Most (95%) had a written sun protection policy. The most common policy inclusions were hat wearing (91%), sunscreen use (87%) and enforcement of policy (97%). Less frequently reported inclusions were protective clothing (69%), information for parents/caregivers (58%) and regular reviews/updates of policies (65%). Basic sun protection practices (e.g. required any type of hat and sunscreen use) were more commonly reported than extensive practices (required protective clothing or regularly applied sunscreen). Higher sun protection policy scores, being a formal childcare service as opposed to a kindergarten/pre-school and having SunSmart status as opposed to not, were associated with higher sun protection practice scores (P < 0.001). Sun protection policies may be improved through encouraging services to have more specific policy inclusions and to model their policies on the SunSmart Early Childhood Program.Kerry A. Ettridge, Jacqueline A. Bowden, Joanne M. Rayner, and Carlene J. Wilso