Showing leads to doing: graphic cigarette warning labels are an effective public health policy

Abstract

Sir Ruiter and Kok1 criticize a study we published in the American Journal of Public Health , which found that smokers who experienced greater emotional reactions in response to graphic cigarette warning labels in Canada were more likely to engage in cessation behaviour at follow-up.2 Ruiter and Kok conclude that: ‘Policy makers should…be reluctant to introduce cigarette warning labels and should instead focus on more effective interventions and policies.’ We strongly disagree. We believe that graphic labels are a vital component of a comprehensive approach to tobacco control. Ruiter and Kok raise a number of concerns about our study. First, they question the validity of self-report measures. Bias in self-report related to smoking is a concern among populations where social desirability bias is strong (notably among underage youth and pregnant women). However, biochemical validation of self-reported measures indicates that the accuracy of self-report is generally high, particularly within observational studies, interviewer-administered surveys, and among adults-all features of our study.3 In addition, we used the same questions and mode of survey (random-digit dial telephone methodology) as the ‘gold standard’ national surveys of adult smoking behaviour in the United States and Canada.4 Perhaps most important, even if our sample was over-reporting intentions to quit or abstinence at …