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Ann Behav Med. 2018 Feb 17;52(3):204-215. doi: 10.1093/abm/kax042.

Enhancing Smoking Risk Communications: The Influence of Health Literacy and Message Content.

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Department of Health Disparities Research, University of Texas MD Anderson Cancer Center, Houston, USA.
Center for Health Outcomes and Population Equity, University of Utah, Salt Lake City, USA.
Stephenson Cancer Center and the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, USA.
Department of Medical and Clinical Psychology, Uniformed Services University of the Health Services, Bethesda, USA.
Division of Population Science, Health Outcomes, and Behavior, Moffitt Cancer Center, Tampa, USA.
Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, USA.



Efforts are needed to ensure that smokers with lower health literacy are provided with understandable and impactful information about the health consequences of smoking and benefits of quitting.


To test the influence of health literacy on smokers' responses to health risk messages manipulated on framing (gain vs. loss) and emotionality (factual vs. emotional).


Participants (N = 402) were randomized to evaluate one of four sets of smoking risk messages (factual gain-framed, factual loss-framed, emotional gain-framed, or emotional loss-framed). Multiple linear regressions examined main effects of health literacy, message emotionality, and message framing on: (a) risk perceptions, (b) behavioral expectations (i.e. cut down, limit, quit), and (c) risk knowledge. Two-way interactions of health literacy with emotionality and framing were examined for these outcomes. Analyses were based on theory-driven, a priori hypotheses.


As hypothesized, main effects emerged such that smokers with higher health literacy reported stronger risk perceptions and knowledge retention regardless of message type. Additionally, emotional (vs. factual) and gain- (vs. loss-) framed messages were associated with certain lower risk perceptions regardless of health literacy level. Consistent with hypotheses, two-way crossover interactions emerged between health literacy and emotionality. Among smokers with higher health literacy, factual messages produced higher perceived risk and stronger expectations for quitting. Among smokers with lower health literacy, emotional messages produced higher perceived risk and stronger expectations for quitting.


Health literacy plays an important role in influencing how smokers respond to different risk messages. One's health literacy should be considered when determining whether risk communications emphasize factual or emotional content.

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