Graphic Warning Labels Research Articles

Graphic warnings and text warning labels on cigarette packages in Riyadh Kingdom of Saudi Arabia: Awareness and perceptions.

BACKGROUND:Graphic warning labels have been shown to be effective in smoking initiation and cessation and were implemented in Saudi Arabia in 2012. To date, no study has assessed the effectiveness of these labels and the Saudi population's perceptions on the effectiveness of cigarette health warning labels.METHODS:We used a cross-sectional qualitative study comprising of nine focus groups among 3 different community group members including health-care workers, adult women and adult men. We conducted in-depth interviews among community leaders. Both focus groups and interviews assessed awareness levels and elicited perceptions about health warning labels on cigarette boxes currently used in the Kingdom of Saudi Arabia.RESULTS:While most participants in the study were aware and supported the use of graphic warning labels on cigarette packages, the awareness of the specific details on the labels was low. Participants perceived the effectiveness of current labels somewhat vague in smoking cessation and advocated for stronger and more aggressive graphics. Community leaders, however, preferred text-only labels and did not support aggressive labels which were deemed culturally and religiously inappropriate.CONCLUSIONS:The study suggests that while graphic warning labels are perceived as necessary on cigarette packages the currently used messages are not clear and therefore do not serve their intended purposes. Measures should be undertaken to ensure that pictorial cigarette labels used in Saudi Arabia are culturally and ethnically appropriate and are rotated on a regular basis to ensure salience among smokers and nonsmokers alike.

Effects of Varying Color, Imagery, and Text of Cigarette Package Warning Labels among Socioeconomically Disadvantaged Middle School Youth and Adult Smokers

ABSTRACTThe U.S. Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 paved the way for the Food and Drug Administration (FDA) to propose nine different graphic warning labels (GWLs) intended for prominent placement on the front and back of cigarette packs and on cigarette advertisements. Those GWLs were adjudicated as unconstitutional on the ground that they unnecessarily infringed tobacco companies’ free speech without sufficiently advancing the government’s public health interests. This study examines whether less extensive alternatives to the original full-color GWLs, including black-and-white GWLs and text-only options, have similar or divergent effects on visual attention, negative affect, and health risk beliefs. We used a mobile media research lab to conduct a randomized experiment with two populations residing in socioeconomically disadvantaged communities: biochemically confirmed adult smokers (N = 313) and middle school youth (N = 340). Results indicate that full-color GWLs capture attention for longer than black-and-white GWLs among both youth and adult smokers. Among adults, packages with GWLs (in either color or black-and-white) engendered more negative affect than those with text-only labels, while text-only produced greater negative affect than the packages with brand imagery only. Among youth, GWLs and text-only labels produced comparable levels of negative affect, albeit more so than brand imagery. We thus offer mixed findings related to the claim that a less extensive alternative could satisfy the government’s compelling public health interest to reduce cigarette smoking rates.

Effects of 30% and 50% Cigarette Pack Graphic Warning Labels on Visual Attention, Negative Affect, Quit Intentions, and Smoking Susceptibility among Disadvantaged Populations in the United States.

Though the WHO Framework Convention for Tobacco Control (FCTC) calls for the implementation of large graphic warning labels (GWLs) on cigarette boxes, the courts have blocked the implementation of 50% labels in the United States. We conducted an experiment to explore whether changing the size of GWLs is associated with changes in visual attention, negative affect, risk beliefs, and behavioral intentions. We recruited adult smokers (N = 238) and middle-school youth (N = 237) throughout the state of New York in May 2016. We randomly assigned participants to one of three between-subject conditions (no GWL [control], 30% GWL, 50% GWL). Adult and youth participants looked at the GWLs longer when the GWL covered 50% versus 30% of the pack's front. Increasing GWL size from 30% to 50% did not influence negative affect or risk beliefs, though both GWL sizes increased negative affect relative to the no-GWL control group. Exposure to 50% GWLs increased adult smokers' intentions to quit compared to no-GWL, but smokers exposed to 30% GWLs did not differ from control. There were no differences between 50% GWLs, 30% GWLs, and control on youth smoking susceptibility. Findings provide some evidence of the benefits of a 50% versus 30% GWL covering the front of the pack for adult smokers and at-risk youth from socioeconomically disadvantaged backgrounds-though not on all outcomes. This research shows that 30% GWLs on cigarette packages increase negative affect relative to packages without front-of-package GWLs. Larger GWLs on cigarette packages (50% vs. 30%) increase visual attention to the warning and its pictorial content among low-SES smokers and at-risk youth but do not further increase negative affect. A 50% GWL increased adults' quit intention compared to no GWL at all, but we were underpowered to detect modest differences in quit intentions between a 50% and 30% GWL. Future work should thus continue to explore the boundary conditions under which relatively larger GWLs influence cognitive, affective, and behavioral outcomes.

A Qualitative Study of Attitudes towards Smoking and Anti-Smoking Measures among Korean Male Smokers in Australia

The study aims to explore how Korean male smokers living in Australia talk and feel about smoking and how they have understood and experienced tobacco control policies in Australia—including price increase, display ban, plain packaging, and graphic warning labels. A qualitative study was conducted based on in-depth face-to-face interviews with 8 Korean male smokers aged 23–40 years living in Canberra. Participants discussed social and cultural conditions in Korea under which smoking is practiced and maintained. Smoking as a means of socialising and relaxation were consistently discussed as the main reasons for continued smoking which was deeply embedded in their everyday lives as habit or part of routines. The health risks of smoking were not among the immediate or ultimate considerations influencing participants. Participants commented that price increases had affected them most but other measures had little impact on their smoking behaviours, although they acknowledged their potentials in deterring younger people. Future anti-smoking interventions in Korea should address the significant social and cultural determinants of smoking and acknowledge smokers’ own understanding of their smoking and anti-smoking measures. Appreciating smokers’ diverse representations of their own smoking and their attitudes towards health and anti-smoking measures would increase acceptance of policies and the probability that they will be successful, leading to positive outcomes.

Older African American Homeless-Experienced Smokers' Attitudes Toward Tobacco Control Policies-Results from the HOPE HOME Study.

To examine attitudes toward tobacco control policies among older African American homeless-experienced smokers. A qualitative study. Oakland, California. Twenty-two African American older homeless-experienced smokers who were part of a longitudinal study on health and health-related outcomes (Health Outcomes of People Experiencing Homelessness in Older Middle Age Study). We conducted in-depth, semistructured interviews with each participant to explore beliefs and attitudes toward tobacco use and cessation, barriers to smoking cessation, and attitudes toward current tobacco control strategies including raising cigarette prices, smoke-free policies, and graphic warning labels. We used a grounded theory approach to analyze the transcripts. Community social norms supportive of cigarette smoking and co-use of tobacco with other illicit substances were strong motivators of initiation and maintenance of tobacco use. Self-reported barriers to cessation included nicotine dependence, the experience of being homeless, fatalistic attitudes toward smoking cessation, substance use, and exposure to tobacco industry marketing. While participants were cognizant of current tobacco control policies and interventions for cessation, they felt that they were not specific enough for African Americans experiencing homelessness. Participants expressed strong support for strategies that de-normalized tobacco use and advertised the harmful effects of tobacco. Older African American homeless-experienced smokers face significant barriers to smoking cessation. Interventions that advertise the harmful effects of tobacco may be effective in stimulating smoking cessation among this population.

Sigara Paketlerinde Bulunan Birleşik Sağlık Uyarılarının Etkinliğinin Sosyal Pazarlama Açısından Değerlendirilmesi

1. GirisSigara her yil dunyada yaklasik 6 milyon insanin hayatini kaybetmesine sebep olan onemli bir saglik sorunudur (WHO, 2015). Ulkemizde ilki 2008 yilinda yapilan Kuresel Yetiskin Tutun Arastirmasi'nin 2012 yilinda yayimlanan son raporunda 15 yas ve ustu bireylerin % 27'sinin sigara ve herhangi baska bir tutun mamulu kullandiklari gorulmektedir. Buna karsin, tutun ve tutun mamullerini birakmayi planlayanlarin oraninda belirtilen bu 4 sene icerisinde yaklasik %8'lik bir artis oldugu gorulmustur (THSK, 2012). Benzer sekilde Turkiye'de 2009 senesi yillik sigara tuketimi 107 milyar paketten fazlayken, yapilan yasal duzenlemelerle bu sayi 2014 senesinde 95 milyar pakete gerilemistir (TAPDK, 2015). Sigara icme oranindaki bu azalmalara ragmen 2014 OECD raporu, Turkiye'nin Avrupa Birligi icerisinde Yunanistan, Litvanya, Kibris, Hirvatistan, Estonya, Ispanya, Macaristan, Sirbistan ve Fransa'dan sonra en cok sigara icilen ulke konumunda oldugunu gostermektedir. Ayrica rapora gore, ulkemizde 15 yas ve ustu bireylerin % 24'u gunluk sigara tuketicisi konumundadir. Bu sonuc, sigara tuketiminin ulkemizde halen onemli bir problem oldugunu gostermektedir (OECD, 2014).Sigara icmek bireylere ve ekonomiye uzun vadeli zararlari olan tehlikeli bir aliskanliktir. Nitekim artan saglik harcamalari, ekonomi uzerinde onemli bir yuk teskil etmektedir. Ekpu ve Brown (2015) yuksek gelire sahip ulkelerde, saglik masraflarinin % 15'ini tutun urunlerinden kaynaklanan hastaliklardan olusturdugunu belirtmistir. Bu bakimdan sigarayla olan savasta en temel gorev aslinda devlete dusmektedir. 18 - 20 Kasim 2015 tarihlerinde gerceklestirilen Ulusal Tutun Kontrol Eylem Plani Calistayi, 2016 senesiyle birlikte tutunle mucadeleyi onemli bir amac olarak belirlemistir (Havani Koru, 2016). Turkiye'nin sigaraya karsi gelistirmis oldugu politikalar cercevesinde sigara reklamlari yasaklanmis, sigara ve tutun urunlerine uygulanan vergi oranlari arttirilmis ve sigara paketlerinde birlesik saglik uyarilarinin bulunmasi zorunlu kilinmistir.Sigara birlesik saglik uyarilarinin etkinligi, basta saglik sektoru olmak uzere pazarlama ve iletisim bilim insanlari tarafindan arastirilan bir konudur. Ancak, sigara birlesik saglik uyarilarinin ne kadar etkili oldugu hakkinda elde edilen bulgularin birbirini destekler nitelikte olmadigi gorulmektedir. Buna gore bazi arastirmalar, birlesik saglik uyarilarinin etkili olmadigini ifade ederken, birlesik saglik uyarilarinin sigarayi birakma, sigaraya baslamama anlaminda faydali oldugunu ifade eden calismalar da mevcuttur (Mazlum ve Mazlum, 2014; Veer ve Rank, 2012; Lindstrom ve Underhill, 2010; Cheron, 2015; Ozkaya, Edinsel, Ozkaya ve Hamzacebi, 2009). Bu noktadan yola cikan bu arastirma Turkiye'de yururlukte olan birlesik saglik uyarilarindan hangilerinin ne oranda etkili olarak algilandigini arastirmayi amaclamaktadir. Ayrica, etkili olarak algilanma durumuyla ile cinsiyet, yas ve sigara icme duzeylerinin birbirinden bagimsiz olup olmadigi da arastirmanin bir diger amacini olusturmaktadir. Bu bakimdan arastirmanin, birlesik saglik uyarilarinin etkinliginin anlasilmasi bakimindan literature katki saglayacagi dusunulmektedir.2. Saglik Alaninda Sosyal Pazarlamanin KullanimiPazarlama, urunlerin hedef pazara yonelik bir sekilde uretilmesi ve satilmasina iliskin problemlere cozum uretmek adina gelistirilmistir. Ancak insanlarin bilinc seviyesi, rekabet, ekonomi ve iletisim teknolojilerinin gelismesiyle birlikte, pazarlamanin ilgilendigi alanlar da cesitlenmistir. Pazarlama gunumuzde yasamin her alaninda kullanilan bir olgu haline gelmistir. Bu kapsamda is arayan bir bireyin deneyim ve becerilerini anlatmasi; politika yapicilarin fikirlerini hitap ettikleri kitlelere aktarmasi pazarlama uygulamalarina ornek teskil etmektedir. Benzer sekilde, toplum yararini gozeterek birtakim olumlu davranislarin gelismesini saglamak da pazarlamanin ilgi alanina girmektedir. Icinde bulundugu toplum, cevre ve dogaya faydali olmayi amaclayan bu tur pazarlama faaliyetleri sosyal pazarlama olarak tanimlanmaktadir (Bayraktaroglu ve Ilter, 2007). …

Disgust but not Health Anxiety Graphic Warning Labels Reduce Motivated Attention in Smokers: A Study of P300 and Late Positive Potential Responses.

Graphic health warning labels (GHWLs) on tobacco products attempt to leverage avoidance-promoting emotions, such as anxiety and disgust, to encourage cessation. Prior studies have relied on self-report or attentional metrics that may not accurately illuminate GHWLs' ability to motivate change. This report evaluates the impact of disgust- and anxiety-based GHWLs on electroencephalograph (EEG) measures of motivated attention among two groups of smokers-those that report higher versus lower cigarette dependence. We hypothesized that both anxiety and disgust GHWLs would reduce appetitive attention, as indexed by lowered P300 (P3) and late positive potential (LPP) activations. Sixty-one smokers provided demographic and smoking history before completing an oddball paradigm consisting of three counterbalanced stimuli blocks. Each block (100 trials) contained a neutral, GHWL-anxiety, or GHWL-disgust frequent image and a smoking cue as the oddball image (20%). Oddball trials for each block were averaged, P3 and LPP were identified at midline electrode positions (Fz, Cz, and Pz), and mean amplitude was analyzed. Separate mixed-model ANOVAs of P3 and LPP reactivity revealed disgust-focused GHWLs reduced motivated attentional processing. Conversely, the anxiety-focused GHWL appeared to increase the salience of the smoking cue (Fz only). Less-dependent smokers showed lower P3 reactivity than those with higher dependence at Fz, but greater P3 reactivity at Cz and Pz. These results extend prior work in demonstrating that disgust, but not anxiety-based GHWLs, may reduce EEG-assessed motivated attention to smoking cues. Disgust may thus represent a more fruitful target for public health cessation efforts. Most GHWL evaluations have focused on fear (or anxiety) elicitation rather than disgust, an emotion that may have a unique link to smoking, having evolved specifically to facilitate the avoidance of contaminants via oral incorporation. Analyses of P300 and LPP responses to GHWLs suggest that disgust-focused images interfere with the EEG-indexed attentional processing of smoking cues and do so better than health anxiety-focused messages. However, interaction effects at different electrode sites indicated that GHWLs have complex effects in more versus less-dependent smokers and that an understanding of how smoking cues and anti-smoking imagery become associated over time is needed to identify relevant targets for public health efforts.

Cigarette graphic warning labels increase both risk perceptions and smoking myth endorsement

Objective: Cigarette graphic warning labels elicit negative emotion, which increases risk perceptions through multiple processes. We examined whether this emotion simultaneously affects motivated cognitions like smoking myth endorsement (e.g. ‘exercise can undo the negative effects of smoking’) and perceptions of cigarette danger versus other products.Design: 736 adult and 469 teen smokers/vulnerable smokers viewed one of three warning label types (text-only, low emotion graphic or high emotion graphic) four times over two weeks.Main outcome measures: Emotional reactions to the warnings were reported during the first and fourth exposures. Participants reported how often they considered the warnings, smoking myth endorsement, risk perceptions and perceptions of cigarette danger relative to smokeless tobacco and electronic cigarettes.Results: In structural equation models, emotional reactions influenced risk perceptions and smoking myth endorsement through two processes. Emotion acted as information about risk, directly increasing smoking risk perceptions and decreasing smoking myth endorsement. Emotion also acted as a spotlight, motivating consideration of the warning information. Warning consideration increased risk perceptions, but also increased smoking myth endorsement. Emotional reactions to warnings decreased perceptions of cigarette danger relative to other products.Conclusions: Emotional reactions to cigarette warnings increase smoking risk perceptions, but also smoking myth endorsement and misperceptions that cigarettes are less dangerous than potentially harm-reducing tobacco products.

The Effects of Graphic Warning Labels' Vividness on Message Engagement and Intentions to Quit Smoking.

The current study examined the effects of manipulating the level of vividness through the presence of various textual and visual components in the context of tobacco warning labels. An online experiment was conducted (N=2165) to examine whether increasing the vividness of warning labels, using narrative and non-narrative components, increased engagement with the messages, and the subsequent effects of vividness and engagement on intentions to quit smoking. Results showed that more vivid warning labels led to increased engagement, which in turn was linked to increased intentions to quit smoking. Specifically, the indirect effect of vividness on intentions to quit smoking was largely driven by the emotional component of engagement. Indirect effects of cognitive engagement were only apparent at higher levels of vividness.

Addiction Treatment Clients' Reactions to Graphic Warning Labels on Cigarette Packs.

Graphic warning labels (GWLs) on cigarette packs have been tested among diverse groups at high risk for tobacco use. However, little is known about the effectiveness of GWL interventions for persons with substance use disorders, whose smoking prevalence is 3 to 4 times that of the general population. After an experimental study which exposed clients in residential addiction treatment to GWLs for 30 days, we conducted five focus groups with trial participants (N = 33) to explore how exposure to the labels may have impacted their readiness to quit smoking. Focus group interviews were analyzed thematically. Interviewees reported that GWLs were more effective than text-based warnings for increasing quit intentions due to greater cognitive and emotional impact. Male and female interviewees expressed gender-specific reactions to the labels. Addiction treatment programs are a strategic site for GWL and other tobacco interventions due to the tobacco-vulnerable populations they serve.

Cigarette graphic health warning labels and information avoidance among individuals from low socioeconomic position in the U.S.

Although graphic health warning labels (GHWs) on cigarette packs have influenced cessation behaviors in other countries, no U.S. studies have explored the impact of avoidance of GHW content among individuals from low socioeconomic position (SEP). The purpose of this study was to determine the predictors of intention to avoid GHWs, and how avoidance impacts cessation intention, in a low SEP sample in the U.S. Data come from low SEP smokers (n = 541) involved in a field experiment. The participants responded to questions pre- and post viewing of GHWs assessing SEP, intention to avoid them, emotional reactions, and intention to seek health information or quit smoking. Backwards stepwise logistic regression determined the predictors for intention to avoid GHWs. Simple and adjusted logistic regression analyzed the association between avoidance and its main predictors and outcomes of intentions to seek information or quit smoking. Predictors for avoidance included being somewhat addicted to cigarettes (OR 2.3, p = 0.002), younger than 25 (OR 2.6, p = 0.008), and having medium (OR 3.4, p < 0.001) or high (OR 4.7, p < 0.001) levels of negative emotional reaction to the labels. Intention to avoid GHWs was positively associated with the intent to look for health information about smoking (OR 2.2, p = 0.002). Higher levels of negative emotional reaction were positively associated with cessation behaviors, with high negative emotional reaction associated with nine times the odds of quitting (p < 0.001). Results indicate avoidance of GHWs does not detract from the labels' benefit and that GHWs are an effective means of communicating smoking risk information among low SEP groups.

Neural correlates of graphic cigarette warning labels predict smoking cessation relapse

Exposure to graphic warning labels (GWLs) on cigarette packaging has been found to produce heightened activity in brain regions central to emotional processing and higher-order cognitive processes. The current study extends this literature by using functional magnetic resonance imaging (fMRI) to investigate neural activation in response to GWLs and use it to predict relapse in an evidence-based smoking cessation treatment program. Participants were 48 treatment-seeking nicotine-dependent smokers who completed an fMRI paradigm in which they were exposed to GWLs, text-only warning labels (TOLs), and matched control stimuli. Subsequently, they enrolled in smoking cessation treatment and their smoking behavior was monitored. Activation in bilateral amygdala, right dorsolateral prefrontal cortex, right inferior frontal gyrus, left medial temporal gyrus, bilateral occipital lobe, and bilateral fusiform gyrus was greater during GWLs than TOLs. Neural response in the ventromedial prefrontal cortex (vmPFC) during exposure to GWLs (relative to a visual control image) predicted relapse during treatment beyond baseline demographic and dependence severity, but response in the amygdala to GWLs did not. These findings suggest that neurocognitive processes in the vmPFC may be critical to understanding how GWL's induce behavior change and may be useful as a predictor of smoking cessation treatment prognosis.

Graphic Warning Labels and the Cost Savings from Reduced Smoking among Pregnant Women

Introduction: The U.S. Food and Drug Administration (FDA) has estimated the economic impact of Graphic Warning Labels (GWLs). By omitting the impact on tobacco consumption by pregnant women, the FDA analysis underestimates the economic benefits that would occur from the proposed regulations. There is a strong link between the occurrence of low birth weight babies and smoking while pregnant. Low birth weight babies in turn generate much higher hospital costs than normal birth weight babies. This study aims to fill the gap by quantifying the national hospital cost savings from the reductions in prenatal smoking that will arise if GWLs are implemented in the U.S. Data and Methods: This study uses several data sources. It uses Natality Data from the National Vital Statistics System of the National Center for Health Statistics (NCHS) in 2013 to estimate the impact of prenatal smoking on the likelihood of having a low-birth-weight baby, controlling for socio-economic and demographic characteristics as well as medical and non-medical risk factors. Using these estimates, along with the estimates of Huang et al. (2014) regarding the effect of GWLs on smoking, we calculate the change in the number of LBW (low birth weight) babies resulting from decreased prenatal smoking due to GWLs. Using this estimated change and the estimates from Russell et al. (2007) and AHRQ (2013) on the excess hospital costs of LBW babies, we calculate cost saving that arises from reduced prenatal smoking in response of GWLs. Results and Conclusions: Our results indicated that GWLs for this population could lead to hospital cost savings of 1.2 billion to 2.0 billion dollars over a 30 year horizon.

The Effect of Pack Warning Labels on Quitting and Related Thoughts and Behaviors in a National Cohort of Aboriginal and Torres Strait Islander Smokers.

The high prevalence of smoking among Aboriginal and Torres Strait Islander people in Australia (39%) contributes substantially to health inequalities. This study assesses the impact of warning labels on quitting and related thoughts and behaviors for Aboriginal and Torres Strait Islander smokers. Participants were recruited from communities served by 34 Aboriginal Community Controlled Health Services and communities in the Torres Strait, Australia, using quota sampling. A cohort of 642 daily/weekly smokers completed relevant questions at baseline (April 2012-October 2013) and follow-up (August 2013-August 2014). We considered three baseline predictor variables: noticing warning labels, forgoing cigarettes due to warning labels ("forgoing") and perceiving labels to be effective. Forgoing increased significantly between surveys only for those first surveyed prior to the introduction of plain packs (19% vs. 34%); however, there were no significant interactions between forgoing cigarettes and the introduction of new and enlarged graphic warning labels on plain packaging in any model. Forgoing cigarettes predicted attempting to quit (adjusted odds ratio [AOR]: 1.45, 95% confidence interval [CI]: 1.02-2.06) and, among those who did not want to quit at baseline, wanting to quit at follow-up (AOR: 3.19, 95% CI: 1.06-9.63). Among those less worried about future health effects, all three variables predicted being very worried at follow-up. Often noticing warning labels predicted correct responses to questions about health effects that had featured on warning labels (AOR: 1.84, 95% CI: 1.20-2.82) but not for those not featured. Graphic warning labels appear to have a positive impact on the understanding, concerns and motivations of Aboriginal and Torres Strait Islander smokers and, through these, their quit attempts. Graphic warning labels are likely to be effective for Aboriginal and Torres Strait Islander smokers as they are for the broader Australian population.

The Association between Warning Label Requirements and Cigarette Smoking Prevalence by Education-Findings from the Global Adult Tobacco Survey (GATS).

Introduction: The Guidelines for the implementation of Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) require that cigarette health warning labels should include pictures and take up 50% or more of the principal display area. This study examined how the association between large pictorial warnings, those covering ≥50% of the front and back of the package, and the prevalence of cigarette smoking varies by educational attainment. Methods: We pooled individual-level tobacco use data from the Global Adult Tobacco Survey (GATS) in 18 countries between 2008 and 2013 and linked them with warning label requirements during the same period from the MPOWER database and reports regarding warnings. The respondents’ self-reported exposure to warnings was examined according to education. Logistic regressions were further employed to analyze education-specific associations between large pictorial warnings and smoking prevalence, and whether such association differed by education was examined using an interaction test. Results: At the time of the survey, eight out of 18 countries had imposed graphic warning labels that covered ≥50% of the package. These warnings were associated with a 10.0% (OR = 0.89; 95% CI: 0.81, 0.97; p ≤ 0.01) lower cigarette smoking prevalence among adults with less than a secondary education or no formal education, but not among respondents with at least a secondary education. Less educated respondents were also less likely to be exposed to warnings in all 18 countries. The association between strong warnings and lower smoking prevalence among less educated respondents could be greater if their exposure to warnings increases. Conclusions: Prominent pictorial warning labels can potentially reduce health disparities resulting from smoking across different education levels.

Cigarette Graphic Warning Labels Are Not Created Equal: They Can Increase or Decrease Smokers’ Quit Intentions Relative to Text-only Warnings

Cigarette graphic-warning labels elicit negative emotion. Research suggests negative emotion drives greater risk perceptions and quit intentions through multiple processes. The present research compares text-only warning effectiveness to that of graphic warnings eliciting more or less negative emotion. Nationally representative online panels of 736 adult smokers and 469 teen smokers/vulnerable smokers were randomly assigned to view one of three warning types (text-only, text with low-emotion images, or text with high-emotion images) four times over 2 weeks. Participants recorded their emotional reaction to the warnings (measured as arousal), smoking risk perceptions, and quit intentions. Primary analyses used structural equation modeling. Participants in the high-emotion condition reported greater emotional reaction than text-only participants (bAdult = 0.21; bTeen = 0.27, p's < .004); those in the low-emotion condition reported lower emotional reaction than text-only participants (bAdult = -0.18; bTeen = -0.22, p's < .018). Stronger emotional reaction was associated with increased risk perceptions in both samples (bAdult = 0.66; bTeen = 0.85, p's < .001) and greater quit intentions among adults (bAdult = 1.00, p < .001). Compared to text-only warnings, low-emotion warnings were associated with reduced risk perceptions and quit intentions whereas high-emotion warnings were associated with increased risk perceptions and quit intentions. Warning labels with images that elicit more negative emotional reaction are associated with increased risk perceptions and quit intentions in adults and teens relative to text-only warnings. However, graphic warnings containing images which evoke little emotional reaction can backfire and reduce risk perceptions and quit intentions versus text-only warnings. This research is the first to directly manipulate two emotion levels in sets of nine cigarette graphic warning images and compare them with text-only warnings. Among adult and teen smokers, high-emotion graphic warnings were associated with increased risk perceptions and quit intentions versus text-only warnings. Low-emotion graphic warnings backfired and tended to reduce risk perceptions and quit intentions versus text-only warnings. Policy makers should be aware that merely placing images on cigarette packaging is insufficient to increase smokers' risk perceptions and quit intentions. Low-emotion graphic warnings will not necessarily produce desired population-level benefits relative to text-only or high-emotion warnings.

Do cigarette graphic warnings encourage smokers to attend a smoking cessation programme: a quasi-experimental study

ObjectiveThis study assessed whether exposure to cigarette graphic warning labels (GWLs) increased attendance to a smoking cessation programme.MethodFrom 2014 to 2016, alternating cohorts of smokers in 3 residential drug treatment...

Desensitisation to cigarette package graphic health warnings: a cohort comparison between London and Singapore

ObjectivesWe compared 2 sociocultural cohorts with different duration of exposure to graphic health warning labels (GHWL), to investigate a possible desensitisation to their use. We further studied how a differing...

Attentional effects of self-affirmation in response to graphic antismoking images.

Self-affirmation has been shown to reduce defensive responding to threatening information. However, little is known about the cognitive and attentional processes underlying these effects. In the current eye-movement study, the authors explored whether self-affirmation affects attention allocation (i.e., number of fixations) among those for whom a threatening health message is self-relevant. After a self-affirmation manipulation, 47 smokers and 52 nonsmokers viewed a series of cigarette packs displaying high or low threat smoking-related images accompanied by a brief smoking message containing risk, coping or neutral textual information. Self-affirmed smokers made more fixations to the cigarette packs than did nonaffirmed smokers (across both high and low threat images), whereas self-affirmed nonsmokers made fewer fixations to the cigarette packs than did nonaffirmed nonsmokers (again across both image types). The textual information did not moderate responses. Findings indicate attention-increasing effects of self-affirmation among those for whom the information is self-relevant (smokers) and attention-decreasing effects of self-affirmation among those for whom the information is not self-relevant (nonsmokers). Such findings are consistent with the calibration model of self-affirmation (Griffin & Harris, 2011) in which self-affirmation increases sensitivity to the self-relevance of health-risk information. The use of an implicit measure of visual orienting informs our understanding of the working mechanisms of self-affirmation when encoding health information, and may also hold practical implications for the design and delivery of graphic warning labels. (PsycINFO Database Record

The influence of graphic warning labels on efficacy beliefs and risk perceptions: a qualitative study with low-income, urban smokers.

BackgroundHealth communication theories indicate that messages depicting efficacy and threat might promote behavior change by enhancing individuals’ efficacy beliefs and risk perceptions, but this has received little attention in graphic warning label research. We explored low socioeconomic status (SES) smokers’ perceptions of theory-based graphic warning labels to inform the development of labels to promote smoking cessation.MethodsTwelve graphic warning labels were developed with self-efficacy and response efficacy messages paired with messages portraying high, low, or no threat from smoking. Self-efficacy messages were designed to promote confidence in ability to quit, while response efficacy messages were designed to promote confidence in the ability of the Quitline to aid cessation. From January – February 2014, we conducted in-depth interviews with 25 low SES adult men and women smokers in Baltimore, Maryland, U.S. Participants discussed the labels’ role in their self-efficacy beliefs, response efficacy beliefs about the Quitline, and risk perceptions (including perceived severity of and susceptibility to disease). Data were analyzed through framework analysis, a type of thematic analysis.ResultsEfficacy messages in which participants vicariously experienced the characters’ quit successes were reported as most influential to self-efficacy beliefs. Labels portraying a high threat were reported as most influential to participants’ perceived severity of and susceptibility to smoking risks. Self-efficacy messages alone and paired with high threat were seen as most influential on self-efficacy beliefs. Labels portraying the threat from smoking were most motivational for calling the Quitline, followed by labels showing healthy role models who had successfully quit using the Quitline.ConclusionsRole model-based efficacy messages might enhance the effectiveness of labels by making smokers’ self-efficacy beliefs about quitting most salient and enhancing the perceived efficacy of the Quitline. Threatening messages play an important role in enhancing risk perceptions, but findings suggest that efficacy messages are also important in the impact of labels on beliefs and motivation. Our findings could aid in the development of labels to address smoking disparities among low SES populations in the U.S.