“IF you drink alcohol, THEN you will get cancer” –Investigating how reasoning

accuracy is affected by pictorially presented graphic alcohol warnings

Daniel Zahra1*, Rebecca L. Monk2, and Emma Corder3

1 Department of Psychology, Plymouth University

2 Department of Psychology, Edge Hill University

3 Department of Psychology, Oxford Brookes University

*Corresponding author. Dr Daniel Zahra, C506 Portland Square, Plymouth University,

Plymouth, Devon, PL4 8AA. e: daniel.zahra@plymouth.ac.uk

Running Head: Reasoning accuracy in pictorial warnings

Word Count: 3,486

Key Words: Reasoning, Pictorial Warnings, Visual Imagery, Inferences, Alcohol

Declaration of Interests

This research was funded by the Plymouth University Department of Psychology. The

authors have no conflicts of interest to declare.

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Abstract

Aims: To examine variation in reasoning accuracy when evaluating emotive pictorial health

warnings and their outcomes.

Methods: In Study 1 individuals completed a version of the Wason selection task evaluating

warnings in which content type (Alcohol, Non-Alcohol) and emotional valence (Positive,

Negative) were manipulated using different images. Study2 presented people with If-Then

warnings (alcohol-related or non-alcohol-related) and asked them to evaluate whether certain

outcomes followed.

Results: Study 1 found that when warning messages were about alcohol, there was no

difference in reasoning accuracy between positive and negative content. However, fewer

correct reasoning responses followed exposure to negative general health messages

(t(152)=3.58, p<.001, d=.19). Study 2 suggested that when a warning involves considering

the potential consequences of drinking alcohol, accuracy is improved when the content is

negative. However, when considering outcomes that will result from abstaining from

consumption, accuracy was greatest when the content was positive. This was supported by an

inference by content interaction (F(3,171)=4.11, p< .01, ηp2=.07).

Conclusions: Negative imagery should be used with caution in health warnings. In some

cases the use of pictorial images of negative outcomes may improve reasoning, however,

their use in alcohol-related messages does not appear to be consistently beneficial. Goals for

using pictorial warnings therefore need to be carefully considered when designing such

warnings.

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Highlights

Negative imagery in alcohol warnings does not consistently improve the accuracy of

the inferences people draw from such warnings.

Outcomes of drinking alcohol are judged more accurately when warnings contain

negative imagery.

Outcomes of not drinking alcohol are judged more accurately when warnings contain

positive imagery.

Use of imagery in alcohol warnings should take into account the intended purpose –

whether that is to convey potential risks associated with alcohol consumption, or

promote potential benefits of abstaining.

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1. Introduction

The reasoning processes and cognitions elicited by exposure to health warnings remain a

complex area requiring further examination (Ruiter, Abraham, & Kok, 2001). However, if

heath messages do not elicit accurate reasoning processes, or if they create avoidant

reactions, their behaviour modification goals may be negated. There is therefore a need to

examine these reasoning processes in greater detail. Most health warnings can be reduced to

the form of conditional statements. That is, “If you do p, then q will happen”. The Wason

selection task presents individuals with rules or warnings and a number of situations on cards.

Participants are then asked to indicate which cards must be turned over to determine whether

the rule is true or false (Wason, 1968). Similarly, other conditional reasoning tasks provide

people with information about the state of the world and then ask what can be inferred based

on this information (if-then logic). The manner in which such conditional statements are

approached is not consistent nevertheless. In conditional reasoning tasks, participants appear

to accept more of the logically valid inferences when the content is related to real-world

situations than when the content is based on abstract concepts such as p’s and q’s (Blanchette

& Richards, 2010; Manktelow, 2000). It is also interesting to note that people tend to be more

logical when reasoning about neutral than positive or negative content (Blanchette, 2006;

Blanchette & Richards, 2004), except when the content relates directly to their experiences

(Blanchette, Richards, Melnyk, & Lavda, 2007). Personal salience and emotive content

therefore appear to be important dictates of reasoning processes. Such findings have clear

relevance to understanding warnings on products such as tobacco and alcohol, given that how

an individual thinks about the information presented is likely to guide their behaviour.

However, to the authors’ knowledge, no work has examined how these effects might alter

with the inclusion of emotive visual imagery. This should be of particular interest within

alcohol research as those expected to draw conclusions from alcohol warnings typically have

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some experience with alcohol, or are making decisions about their own current experience.

The fact that the emotional content may influence people’s reasoning processes is also highly

pertinent given the ongoing debate in relation to the use of emotive imagery in alcohol

warnings.

Warnings inform the public of potential hazards and direct people away from unsafe acts or

objectionable behaviours (Stewart & Martin, 1994), and tobacco and alcohol warnings are

now found on packaging worldwide (European Commission, 2012; Ford, Moodie, &

Hastings, 2012; Hammond, 2011). Furthermore, Thailand’s government has proposed that

similar images should be introduced on alcohol packaging (O'Brien, 2013), and the UK’s

Faculty of Public Health (2012) has called for a factual “no-nonsense” approach to

combining warning text and images on alcohol packaging. Accordingly, it has been noted

that the ‘fear appeal’ of health messages is important (Witte, 1998) and there is a strong

theoretical basis for such assertions (Leventhal, 1970; Witte & Allen, 2000). Large scale

reviews and meta-analyses have concluded that effectively designed fear appeals and

pictorial health warnings eliciting strong emotional reactions can effectively reduce smoking

(Hammond, 2011; Witte & Allen, 2000). However, O’Brien (2013) questions the

generalisation from research on smoking to alcohol, especially when evidence in favour of

the utility of graphic alcohol warnings is scarce (Thamarangsi & Puangsuwan, 2010). The

basis for assuming fear in health messages improves efficacy has been criticised (Hastings &

MacFadyen, 2002; Sweet, Willis, Ashida, & Westman, 2003) and neuroimaging research

(Kessels, 2014) indicates that fear arousing messages can create a defensive reaction (Janis,

1967; Witte & Allen, 2000), diverting attention away from the warning. Research on the

effectiveness of such warnings on alcohol packaging is also inconsistent (Wilkinson &

Room, 2009).

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An unclear understating of the cognitive processes which occur in response to graphic

health warnings may be a contributor to this inconsistency. It is therefore necessary to

increase our understating of the cognitive and reasoning processes elicited by pictorial and

emotive alcohol warnings (Agostinelli & Grube, 2002). If these warnings are not inducing the

desired reasoning, then a change of approach may be necessary in order that resources be

better allocated to address alcohol consumption. The aim of this research was therefore to

adapt existing paradigms such as the Wason selection task (using real-world alcohol-related

content) and a conditional reasoning task which replaces verbal terms in real-world

conditional warnings with emotive imagery. Utilising both methodologies allows an

investigation of how people respond to warnings, and an examination of what people infer

given a particular warning and situation. The results are framed in terms of logical accuracy,

and in practical terms relate to how accurate people are in evaluating and drawing

conclusions from such warning labels.

2. Pre-testing of Visual Imagery

In order to construct the necessary visual conditionals, 92 simple, high-resolution, and freely

available images were collected by the authors. Images were compiled into an online format

for presentation to an independent group of participants (N=26; 8 male, 18 female; Mean age

28 years, SD=10.67). Each image was presented separately and participants rated valence and

arousal of each picture using the Self-Assessment Manikin (Figure 1), which has been used to

assess similar visual stimuli (Lang, Bradley, & Cuthbert, 2005)

[Insert Figure 1]

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Images were then formed into pairs which illustrated warnings that were positive or negative,

alcohol-related or not. Based on pre-test ratings, positive pairs were rated as more positive

(M=5.60, SD=0.65) than negative pairs (M=4.59, SD=0.39; F(1,16)=17.15, p=.001, ηp2 =.52),

whilst valence did not vary as a function of content type (Alcohol, M=4.97, SD=0.80; Non-

alcohol, M=5.21, SD=0.68), nor did emotion and content interact (F(1,16)=.12, p=.738, ηp2

=.07). Arousal ratings did not differ as a function of emotion (Positive, M=4.44, SD=0.21;

Negative, M=4.59, SD=0.14) or content type (Alcohol, M=4.54, SD=0.14; Non-alcohol,

M=4.49, SD=0.22), nor was there any interaction (F(1,16)=.54, p=.474, ηp2=.03).

3. Study 1

As outlined above, the Wason selection task requires individuals to test different situations in

order to evaluate the truth of a rule or warning. Applied to alcohol, Griggs and Cox (1982)

report a study where people were told that the law states “If a person is drinking alcohol, then

they must be 21 years old”. They are then asked to imagine they are a police officer entering

a bar where there is a person drinking beer, a person drinking cola, an older gentleman, and a

young child. Their task is to indicate whose age and drink must be determined in order to tell

whether the law is being broken in this scenario. In this case, the correct action is to ascertain

the age of the person drinking beer and determine what the younger person is drinking (by

turning over cards with verbal labels on each side relating to age and drink). If the beer

drinker is under 21 years, or the younger person is drinking alcohol, the law has been broken.

The other cases are irrelevant. The age of the cola drinker and whether the older gentleman is

drinking alcohol or not have no bearing on the law1. The present study adapts this task in

order to investigate how peoples’ evaluations of alcohol-related warnings are affected by the

1 Structurally, this scenario can be represented as “If p (alcohol) then q (21yo)”. The people in the bar represent states of the world corresponding to p (beer), not-p (cola), q (older man) and not-q (child). The ‘correct’ response, which allows a complete, logically valid evaluation of the law, is to choose p and not-q.

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inclusion of emotive visual imagery. By manipulating the valence and presentation of the

warning and available options we can establish the effects of visual imagery (positive or

negative) and warning content (alcoholic or non-alcohol beverages). Of primary interest are

positive and negative alcohol-related warnings as any differences here will speak most

directly to the relative effectiveness of negatively valenced graphic warnings. The inclusion

of non-alcohol related warnings provides a comparison group, whilst also informing us more

generally about the impact of emotive imagery in warnings. In the studies reported here,

alcohol-related warnings focussed on the consumption of a range of alcoholic beverages,

including beers, wines, and spirits, whereas non-alcohol related warnings focussed on the

consumption of fruit juices and water.

3.1 Method

Participants

The 153 people (14 men, 139 women; Age, M=21years SD=5years) who participated were

postgraduate volunteers, or psychology undergraduates participating for course credit.

Scrutiny of the undergraduate psychology programmes from which the students were

sampled showed they are unlikely to have been familiar with the Wason selection task prior

to the current study.

Warning Materials

A variant of the Wason selection task was used in which participants were shown a series of

‘cards’, and a warning. For example, “Each card has a liver on one side and the number of

units of alcohol drank in a week on the other. Which cards must be turned over to test the

warning ‘If you drink more than five units of alcohol in a week, you will develop liver

damage’?” The cards presented depict affirming and negating cases of each part of the

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warning; in this example, >5 units, no alcohol, a healthy liver, and a damaged liver (Figure

2). Participants could then select 1-4 cards before continuing to the next trial.

[Insert Figure 2]

Procedure, Design and Analytic Strategy

Participants completed 40 online trials, consisting of ten positive warnings and ten negative

warnings. Each ten included 5 alcohol-related and 5 non-alcohol-related. For each trial,

participants were presented with the warning and the card options. They were then allowed to

select the card or cards they thought needed to be evaluated to test the warning before moving

on to the next trial. Each of the warnings also appeared with the terms reversed. For example,

“If you drink alcohol then you will become depressed” also appeared as “If you become

depressed then you will drink alcohol”. This controlled for the converse probability of the

conditional statement which has been shown to affect the inferences people draw (Cummins,

Lubart, Alksnis, & Rist, 1991). Data were subject to a 2 Content Type (Alcohol-related, Non-

Alcohol-related) by 2 Emotional Valence (Positive, Negative) repeated-measures ANOVA

which focussed on logically correct responses (the proportion of participants’ responses

where p and not-q were selected). Participants were also asked to complete the AUDIT (26),

a 10-item questionnaire designed to screen for individuals suffering from or at risk of

developing alcohol use disorders. The relationship between AUDIT scores and response

profiles was evaluated using correlational analyses prior to consideration of their inclusion in

the above ANOVA.

3.2 Results

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Table 1 displays descriptive statistics for p-and-not-q choices across trial types, and the

ANOVA revealed a significant main effect of emotional valence (F(1,152)=4.63, p=.03, ηp2

=.03) but not content type (F(1,152)=.002, p=.97, ηp2 < .001).

[Insert Table 1]

Logical accuracy was significantly lower in response to negatively valenced content when

compared to positive content, but there was no difference between alcohol-related and non-

alcohol-related content. These findings were qualified by a significant 2-way interaction

between valence and content (F(1,152)=8.58, p< .01, ηp2 = .05), as shown in Figure 3..

[Insert Figure 3]

Post-hoc repeated measures t-tests reveal that when the warning content is alcohol-related,

emotional valence has no significant impact on how often people choose the logically correct

p and not-q combination. However, when the content is not related to alcohol, positively

valenced items lead to significantly more choices of the logically correct combination than

negatively valenced items (t(152)=3.58, p<.001, d=.19). Scores on the AUDIT showed no

relationship to patterns of responding, or to rates of any response in particular.

3.3 Discussion

These findings suggest that the pictorial presentation of negative health outcomes in health

warnings that are not related to alcohol may have unintended and adverse consequences,

potentially decreasing the accuracy with which people process these warnings, and thus

limiting their potential to positively affect behaviour. However, when warning messages were

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about alcohol, no difference in reasoning accuracy was found between positive and negative

warnings. These findings suggest that pictorial images of negative outcomes do not improve

reasoning about alcohol-related warnings. It may be of interest, however, to note that for both

types of warning in Study 1, accuracy rates are higher than the ~10% typically found for

abstract (lacking real-world content) versions of the selection task (Manktelow, 2000; Wason,

1968).

4. Study 2

Study 1 combined trial valence and content, as well as controlling for image valence and

arousal. However, in real-world warnings valence and content are typically found in certain

combinations. Alcohol warnings are primarily negative (Glock & Krolak-Schwerdt, 2013), as

with smoking warnings (Glock et al., 2013). Indeed, it is for this reason that many have

warned of a potential boomerang effect following exposure to alcohol warnings whereby

readers act contrary to the warning (Ringold, 2002). However, smoking and drinking also

have potentially positive effects (Glock & Krolak-Schwerdt, 2013; Glock et al., 2013). It has

also been noted that alcohol warnings targeting positive expectancies (utilising expectancy-

related messages) may be more effective than negatively worded health warnings. In order to

provide a more ecologically valid comparison of alcohol warnings, study two utilised a

collection of real-world warnings from published work (e.g. Brandish & Sheron, 2010;

Cherpitel et al., 2003; Van Duyn & Pivonka, 2000) which fall into two categories; those

which are negative and alcohol-related, and those which are positive and not alcohol-related.

The terms in these warnings were then replaced with images, and people were asked whether

particular outcomes followed, allowing an investigation of the inferences people accept from

the different warning types.

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4.1 Method

Participants

Participants were 58 (8 men, 50 women; Age, M=22years SD=6years) psychology

undergraduates and postgraduate students participating voluntarily or for course credit (Age,

M=22 years, SD=5.61).

Warning Materials

A collection of real-world warnings were selected which were either negative and about

alcohol, or positive and not about alcohol. Words in these warnings were then replaced with

images, creating ‘visual conditionals’ - “If p then q” statements in which the terms p and q

are substituted for images. In conditional statements, the “If p” component is called the

antecedent, and the “Then q” component the consequent. Additional information presented in

the form of “Given p” is called a premise, and the component being evaluated (“Does it

follow that q?”) is the inference. Conditional statements, premises, and inferences to be

evaluated can be combined to create four problem types. These are commonly referred to in

the reasoning literature as Modus Ponens (MP), Modus Tollens (MT), denial of the

antecedent (DA), and affirmation of the consequent (AC)2. Table 2 details these four

structures, the combinations of premises and inferences which constitute them, and the

logically ‘correct’ responses in evaluation of each inference.

[Insert Table 2]

2 To use the example of Griggs and Cox (1982) again, the logical validity of MP and MT can be seen by considering the statement “If a person is drinking alcohol, they are aged over 21 years”. Assuming it’s truth, which participants are typically instructed to do, by MP, if a person is drinking alcohol, then they will be 21 years old or over. By MT, if the person is not 21 years or over, then they will not be drinking alcohol. However, the rule says nothing at all about how old a person who is not drinking alcohol might be (DA), or what drink people over 21 years old will have (AC).

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Recording how often people respond correctly to each problem type indexes their accuracy in

evaluating inferences drawn from images only. This has implications for the simplification of

warnings to image-only formats such as those that are commonly found in a range of settings,

from road-signs to chemical labelling conventions. Images were chosen from the pool created

for this research and negated instances of the image were represented by placing a large red

cross through the image (Figure 4). This generated a selection of ten statements, five of

which were related to alcohol, and five of which were related to other beverages. Because

each statement could be accompanied by a premise image which affirmed p, denied p,

affirmed q, or denied q, each of 5 negative-alcohol and 5 positive-non-alcohol visual

conditionals appeared in each of the four problem types in Table 2.

[Insert Figure 4]

Procedure, Design, and Analytic Strategy

Participants completed 40 online trials. Content types were blocked together and

counterbalanced, and trials within each block were randomised. Accuracy across trial types

was analysed using a 2 Content Type (Negative-Alcohol, Positive-Non-Alcohol) by 4

Problem Type (MP, MT, DA, AC) repeated measures ANOVA. This facilitated an

investigation of the effect of problem type on people’s accuracy in drawing inferences.

Although this does not allow consideration of the interaction between content and valence as

in Study 1, the aim of Study 2 was to examine the accuracy of participants’ reasoning in

response to types of warning messages typically found in relation to alcohol (negative alcohol

warnings), relative to messages of a more positive nature and which were not related to

alcohol (positive non-alcohol warnings). Reasoning accuracy was defined as the proportion

of formally logically correct responses to each type of problem. For MP, this was the

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proportion of “Yes it follows” responses, for MT, “No” responses were correct For DA and

AC inferences, this was the proportion of “Maybe” responses. AUDIT scores were also

included, as in Study 1.

4.2 Results

Table 3 displays descriptive statistics for the accuracy rates obtained across each trial type.

The ANOVA revealed a significant main effect of problem type (F(2.02,115.24)=170.28,

p< .001, ηp2 =.75), suggesting that participants found MP and MT trials significantly easier

than DA and AC problem types (all LSD post-hoc pairwise comparisons showed significant

differences at p<.05 except between DA and AC inferences).

[Insert Table 3]

Furthermore, although there was no significant difference in response accuracy between

positive-non-alcohol and negative-alcohol trials (F(1,57)=.76, p=.39, ηp2 =.01), content

showed a significant interaction with problem type (F(3,171)=4.11, p<.01, ηp2=.07), which

suggests that negatively valenced alcohol warnings lead to better reasoning on MP and MT

problems, but positively valenced warnings lead to better reasoning on DA and AC problems

(Figure 5). MP shows the largest (and only statistically significant) difference between

Positive-Non-Alcohol and Negative-Alcohol content (t(57)=-3.47, p=.001, d=-.47), followed

by DA, MT, and finally least difference is found on AC problems between the two content

types. Scores on the AUDIT showed no relationship to patterns of responding, or to rates of

any response in particular.

[Insert Figure 5]

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4.3 Discussion

Overall, negative-alcohol content appeared to lead to better reasoning on MP and MT but

worse on DA and AC reasoning tasks. More specifically, the current findings suggest that

negative alcohol-related messages lead to significantly more accurate reasoning in situations

most likely to be pertinent to decisions to drink – “What will happen if I drink?” (MP).

Interestingly, the second largest accuracy difference was for the DA inference –“What will

happen if I don’t drink?” In this case, positive non-alcohol related images elicited higher

accuracy than negative alcohol-related images (although this did not reach statistical

significance). The largest differences in reasoning accuracy therefore appear to result from

health messages which relate to reasoning situations most relevant to a drinker – what will

happen if they drink versus if they do not drink.

5. Overall Discussion

Much of the policy around alcohol warnings has been based on a potential overgeneralisation

of the smoking literature (O'Brien, 2013), and there has been little research which has

examined the conditional reasoning processes in relation to exposure to alcohol warnings,

and how these may be affected by warning content. The current work therefore aimed to

address this knowledge-gap - investigating the impact of content type and emotional valence

in warnings. Specifically this entailed comparing positive and negative imagery across

alcohol-related and non-alcohol related warnings. This was done by developing paradigms

that assess peoples’ evaluation of the warnings themselves (Study 1) and investigating their

evaluation of the implications of the warnings (Study 2). Study 1 found no difference in

accuracy of responses between positive and negative warnings about alcohol. Yet, relative to

positive content, negative content reduced reasoning accuracy on other health related

15

warnings. This would seem to suggest that people are no better at evaluating negative than

positive warnings about alcohol and so there is little to be gained in this domain from making

the content overly negative.

There is a distinction here between evaluating emotional content, and the impact of

any emotion generated by the content. Such a distinction underpins work related to anxiety

avoidance which highlights a psychological immune system or rebound effect. This therefore

suggests a potentially fruitful and informative area of future work. However, the current

results appear contrary to what might be expected following the claims used to justify

recently developed graphic warning labels (Hammond, 2011) and supports the assertion that

graphic images are not necessarily beneficial (Thamarangsi & Puangsuwan, 2010).

Nevertheless, the comparable reasoning accuracy presently revealed across positive and

negative warning conditions suggest that there was equally no evidence that negative warning

images had a more detrimental effect than their positive counterparts. Study 2 was therefore

intended to provide a more ecologically valid comparison of negative alcohol-related

messages in contrast with positive non-alcohol-related messages (those typically intended to

promote healthy lifestyles). Here, results suggest that when warnings about alcohol are

negative, people are more accurate at evaluating what outcomes will follow if they drink

(MP). In this respect, the results of Study 2 seem to suggest that when trying to provide clear,

understandable warnings about the consequences of drinking, accuracy can be improved by

making the content negative. However, in the current study this is only the case when

considering what the outcome will be when you drink alcohol. Such warnings therefore

appear of most relevance to individuals already engaging in, or intending to engage in,

alcohol consumption. If the goal of a public health initiative is to prevent initial alcohol

consumption, people are more accurate (though not significantly so) at determining outcomes

about not drinking alcohol (DA) when the content is positive. Concurrently, there was an

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apparent improvement in the evaluation of non-alcohol warnings when the content is positive

(Study 1). This might be used to improve understanding of the health benefits of activities

other than drinking alcohol.

It should be noted that the current research findings may not represent the cognitive

processes which follow from exposure to alcohol warnings in alcohol-related environments

such as pubs or bars. It has been noted that interaction with alcohol warnings in different

contexts needs further investigation (Thomson, Vandenberg, & Fitzgerald, 2012) and

research has shown that alcohol-related beliefs change across situational and social contexts

(Monk & Heim, 2013a, 2013b). This means that in vivo examinations of alcohol-related

cognitions may not replicate laboratory-based assessments (Monk & Heim, 2013a). Informed

by recent research examining the effectiveness of smoking warnings in real-life contexts

(Glock et al., 2013), future research may therefore be benefited by implementing the current

paradigms in real-life drinking contexts. Nevertheless, the findings from this research offer

important insights for the ongoing debate in relation to the most effective use of pictorial

health warnings on alcohol packaging. It can be regarded as an indication of the need to

carefully align the warning content with the goals of the initiative, and not simply aiming to

startle individuals into compliance.

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References

Agostinelli, G., & Grube, J. W. (2002). Alcohol Counter-Advertising and the Media: A Review of Recent Research. Alcohol Research and Health, 26, 12-21.

Blanchette, I. (2006). The effect of emotion on interpretation and logic in a conditional reasoning task. Memory and Cognition, 34(5), 1112-1125. doi: 10.3758/BF03193257

Blanchette, I., & Richards, A. (2004). Reasoning about emotional and neutral materials. Psychological Science, 15(11), 745-752. doi: 10.1111/j.0956-7976.2004.00751.x

Blanchette, I., & Richards, A. (2010). The influence of affect on higher level cognition: A review of research on interpretation, judgement, decision making, and reasoning. Cognition and Emotion, 24(4), 561-595. doi: 10.1080/02699930903132496

Blanchette, I., Richards, A., Melnyk, L., & Lavda, A. (2007). Reasoning about emotional contents following shocking terrorist attacks: a tale of three cities. Journal of Experimental Psychology: Applied, 13(1), 47-56. doi: 10.1037/1076-898X.13.1.47

Brandish, E., & Sheron, N. (2010). Drinking patterns and the risk of serious liver disease. Expert Review of Gastroenterology and Hepatology, 4(3), 249-252. doi: 10.1586/egh.10.27

Cherpitel, C. J., Borgers, G., Giesbrecht, N., Hungerford, D., Peden, M., Poznyak, V., . . . Stockwell, T. (2003). Alcohol and injuries: Emergency department studies in an international perspective. Geneva: WHO.

Cummins, D. D., Lubart, T., Alksnis, O., & Rist, R. (1991). Conditional reasoning and causation. Memory and Cognition, 19(3), 274-282.

European Commission. (2012). Tobacco packaging heath warning labels. Brussels: http://ec.europa.eu/public_opinion/archi ves/quali/ql_5818_tobacco_en.pdf. alcohol [Accessed October, 2013].

Faculty of Public Health UK. (2012). Health warnings needed on alcohol. Available from:http://www.fph.org.uk/health_ warnings_needed_on_alcohol [Accessed October, 2013].

Ford, A., Moodie, C., & Hastings, G. (2012). The role of packaging for consumer products: understanding the move towards 'plain' tobacco packaging. Addiction Research and Theory, 20(4), 339-347. doi: 10.3109/16066359.2011.632700

Glock, S., & Krolak-Schwerdt, S. (2013). Changing outcome expectancies, drinking intentions, and implicit attitudes toward alcohol: a comparison of positive expectancy-related and health-related alcohol warning labels. Applied Psychology: Health and Well- Being, 5, 332-347. doi: 10.1111/aphw.12013

Glock, S., Ritter, S. M., Engels, R., Dijksterhuis, A., van Baaren, R. B., & Müller, B. C. N. (2013). “Smoking kills” vs.“Smoking makes restless”: Effectiveness of different warning labels on smoking behaviour. Science, 2, 181-187. doi: 10.11648/j.pbs.20130205.12

Griggs, R. A., & Cox, J. R. (1982). The elusive thematic-materials effect in Wason's selection task. British Journal of Psychology, 73(3), 407-420.

Hammond, D. (2011). Health warning messages on tobacco products: a review. Tobacco Control, 20, 327-337. doi: 10.1136/tc.2010.037630

Hastings, G., & MacFadyen, L. (2002). The limitations of fear messages. Tobacco Control, 11, 73-75. doi: 10.1136/tc.11.1.73

Janis, I. L. (1967). Effects of fear arousal on attitude change: Recent developments in theory and experimental research. In L. Berkowitz (Ed.), Advances in Experimental Social Psychology (Vol. 1). New York: Academic Press.

Kessels, L. T. E. (2014). Neuroscientific evidence for defensive avoidance of fear appeals. International Journal of Psychology, 49(2), 80-88. doi: 10.1002/ijop.12036

18

Lang, P. J., Bradley, M. M., & Cuthbert, B. N. (2005). International affective picture system (IAPS): Instruction manual and affective ratings: Technical Report A-6, The Centre for Research in Psychophysiology, University of Florida.

Leventhal, H. (1970). Findings and theory in the study of fear communications. Advances in Experimental Social Psychology, 5, 119-186. doi: 10.1016/S0065-2601(08)60091-X

Manktelow, K. (2000). Reasoning and thinking. Hove: Psychology Press.Monk, R. L., & Heim, D. (2013a). Environmental context effects on alcohol-related outcome

expectancies, efficacy and norms: A field study. Psychology of Addictive Behaviors, 27, 814-818. doi: doi: 10.1037/a0033948.

Monk, R. L., & Heim, D. (2013b). Panoramic projection; affording a wider view on contextual influences on alcohol-related cognitions. Experimental and Clinical Psychopharmacology, 21, 1-7. doi: 10.1037/a0030772

O'Brien, P. (2013). Australia's double standard on Thailand's alcohol warning labels. Drug and Alcohol Review, 32, 5-10. doi: 10.1111/j.1465-3362.2012.00485.x

Ringold, D. (2002). Boomerang effects in response to public health interventions: some unintended consequences in the alcoholic beverage market. Journal of Consumer Policy, 25(1), 27-63. doi: 10.1023/A:1014588126336

Ruiter, R. A. C., Abraham, C., & Kok, G. (2001). Scary warnings and rational precautions: A review of the psychology of fear appeals. Psychology and Health, 16(6), 613-630.

Stewart, D. W., & Martin, I. M. (1994). Intended and unintended consequences of warning messages: a review and synthesis of empirical research. Journal of Public Policy and Marketing, 13(1), 1-19.

Sweet, K. M., Willis, S. K., Ashida, S., & Westman, J. A. (2003). Use of fear-appeal techniques in the design of tailored cancer risk communication messages: implications for healthcare providers. Journal of Clinical Oncology, 21(17), 3375-3376. doi: 10.1200/JCO.2003.99.049

Thamarangsi, T., & Puangsuwan, A. (2010). Why Thailand should have the pictorial warning label on alcoholic beverage packages? Thailand: Centre for Alcohol Studies and International, Health Policy Program, Availible from: http://ihppthaigov.net/pu blication/attachresearch/257/chapter251.pdf. [Accessed Oct 2013].

Thomson, L. M., Vandenberg, B., & Fitzgerald, J. L. (2012). An exploratory study of drinkers views of health information and warning labels on alchohol containers. Drug and Alcohol Review, 31(2), 240-247. doi: 10.1111/j.1465-3362.2011.00343.x

Van Duyn, M. A., & Pivonka, E. (2000). Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: selected literature. Journal of the American Dietetic Association, 100(12), 1511-1512. doi: 10.1016/S0002-8223(00)00420-X

Wason, P. C. (1968). Reasoning about a rule. The Quarterly Journal of Experimental Psychology, 20(3), 273-281. doi: 10.1080/14640746808400161

Wilkinson, C., & Room, R. (2009). Warnings on alcohol containers and advertisements: International experience and evidence on effects. Drug and Alcohol Review, 28, 426-435. doi: 10.1111/j.1465-3362.2009.00055.x.

Witte, K. (1998). A theoretically based evaluation of HIV/AIDS prevention campaigns along the trans-Africa highway in Kenya. Journal of Health Communication, 3, 345-363. doi: 10.1080/108107398127157

Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education and Behavior, 27, 591-615. doi: 10.1177/109019810002700506

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Figure 1Self-Assessment Manikin used by participants to rate each image for valence and arousal

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Figure 2Example format of the Wason selection task presented in Study 1.

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Figure 3Percentage of trials responded to with selection of p-and-not-q (logically correct) by content type and emotional valence (Error bras: 95%CI).

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Figure 4Example of a visual conditional from Study 2

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Figure 5Interaction between problem type and content type on reasoning accuracy (Error bras: 95%CI).

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Table 1Percentage of trials responded to with p-and-not-q selections (accuracy) by content type and emotional valence.

Logically correct (p and not-q) TotalContent Alcohol Non-alcoholValence Positive 26.54 (31.96) 29.67 (31.26) 28.11 (31.61)

Negative 26.86 (32.72) 23.66 (32.66) 25.26 (32.69)

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Table 2Image pairs presented accompanying “If p, then q” for each possible problem type (inference), including the logically correct response for each type of problem.

Problem Type Presentation Pair Correct Response

MP Given p Does q follow? YMT Given not-q Does p follow? NDA Given not-p Does q follow? MAC Given q Does p follow? M

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Table 3Participants’ reasoning accuracy (%) by problem type and warning content (N=58 for all cells).

Problem Type

Negative-Alcohol Positive-Non-Alcohol TotalM SD M SD M SD

MP 85.09 23.29 74.83 20.71 79.96 22.00MT 75.78 29.20 71.38 30.00 73.58 29.60DA 16.21 24.70 22.76 18.90 19.48 21.80AC 17.59 24.30 19.66 24.99 18.62 24.65Total 48.66 25.37 47.16 23.65 47.91 24.51

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