Graphic Warnings Research Articles

Emotional reaction facilitates the brain and behavioural impact of graphic cigarette warning labels in smokers

BackgroundWarning labels on cigarette packages are an important venue for information about the hazards of smoking. The 2009 US Family Smoking Prevention and Tobacco Control Act mandated replacing the current...

Testing warning messages on smokers’ cigarette packages: a standardised protocol

PurposeLab experiments on cigarette warnings typically use a brief one-time exposure that is not paired with the cigarette packs smokers use every day, leaving open the question of how repeated...

Accounting for "lost pleasure" in a cost-benefit analysis of government regulation: the case of the Food and Drug Administration's proposed cigarette labeling regulation.

The U.S. Food and Drug Administration (FDA) prepared an economic impact analysis of a proposed rule for graphic warning labels on tobacco products. This commentary discusses the analysis and finds ...

Assessing tobacco regulation: moving beyond economists.

US presidents since Ronald Reagan have required regulatory agencies to conduct cost-benefit analyses of proposed regulations,1 currently governed by Office of Management and Budget Circular A-4.2 On its surface, requiring such analyses makes sense; after all, why burden businesses with costly regulations if there is little benefit to the public? There are, however, several problems with cost-benefit analysis, including the facts that the costs are often borne by different people than receive the benefits, the tendency of cost-benefit analysis to overstate costs and understate benefits and the pro-business bias within the economics profession.3 The net effect of requiring cost-benefit analyses is to make it more difficult to develop, implement and defend regulations to protect public health and the environment. These problems are clearly manifest in the cost-benefit analyses done for the proposed tobacco product regulations by the US Food and Drug Administration (FDA), first as part of its unsuccessful 2011 attempt to require graphic warning labels on cigarette packages4 and its 2013 proposal to assert jurisdiction over non-cigarette tobacco products.5 In both cases, the FDA grossly underestimated benefits and overstated costs. We6 criticised the cost-benefit analysis of the warning label rule4 on the grounds that it discounted any health benefits by 50% to account for the lost ‘consumer surplus’ that would result from smokers being denied the pleasure of smoking. …

Adolescents Perceptions of Pro- and Antitobacco Imagery and Marketing: Qualitative Study of Students from Suva, Fiji.

Background. Many studies examining smoking uptake among young people in the Pacific have not included their exposure to tobacco control promotions in the media in their assessment. This study examines how Fijian students view tobacco and tobacco-related media depictions to gain insight into both drivers of smoking uptake and potential directions for prevention interventions. Methods. A sample of thirty Fijian students (15 male and 15 female) aged 14–17 years, was recruited from a Suva school between September and October 2013 and participated in a one-to-one in-depth interview about their views on tobacco use, media consumption patterns and preferences and awareness of tobacco use in media. Results. Despite radical developments in access to media, television remains the most popular. Yet, the majority of participants were unaware of any protobacco imagery on television or other entertainment media. Tobacco-related imagery was more likely to be seen in connection with point of sale advertising and branding. The advertising potential of the shop counter was acutely apparent to some participants and this space was considered highly influential. Conclusions. Despite the fact that the recently introduced graphic health warnings were generally well received, more can be done to extend the use of media for tobacco control benefits in Fiji.

Refuting tobacco-industry funded research: empirical data shows decline in smoking prevalence following introduction of plain packaging in Australia

1. Framework Convention on Tobacco Control. Guidelines forImplementation of Article 11 (Packaging and Labelling of Tobacco Products). 2008. Available from: http://www.who.int/entity/fctc... (accessed 11 Oct 2015). Google Scholar

Responses of young adults to graphic warning labels for cigarette packages

Responses of young adults to graphic warning labels for cigarette packages

An evaluation of the FDA's analysis of the costs and benefits of the graphic warning label regulation

The Family Smoking Prevention and Tobacco Control Act of 2009 gave the Food and Drug Administration (FDA) regulatory authority over cigarettes and smokeless tobacco products and authorised it to assert...

Standardised (plain) cigarette packaging increases attention to both text-based and graphical health warnings: experimental evidence

ObjectiveTo investigate whether standardised cigarette packaging increases the time spent looking at health warnings, regardless of the format of those warnings. Study designA factorial (two pack styles x three warning types) within-subject experiment, with participants randomised to different orders of conditions, completed at a university in London, UK. MethodsMock-ups of cigarette packets were presented to participants with their branded portion in either standardised (plain) or manufacturer-designed (branded) format. Health warnings were present on all packets, representing all three types currently in use in the UK: black & white text, colour text, or colour images with accompanying text. Gaze position was recorded using a specialised eye tracker, providing the main outcome measure, which was the mean proportion of a five-second viewing period spent gazing at the warning-label region of the packet. ResultsAn opportunity sample of 30 (six male, mean age = 23) young adults met the following inclusion criteria: 1) not currently a smoker; 2) <100 lifetime cigarettes smoked; 3) gaze position successfully tracked for > 50% viewing time. These participants spent a greater proportion of the available time gazing at the warning-label region when the branded section of the pack was standardised (following current Australian guidelines) rather than containing the manufacturer's preferred design (mean difference in proportions = 0.078, 95% confidence interval 0.049 to 0.106, p < 0.001). There was no evidence that this effect varied based on the type of warning label (black & white text vs. colour text vs. colour image & text; interaction p = 0.295). ConclusionsDuring incidental viewing of cigarette packets, young adult never-smokers are likely to spend more time looking at health warnings if manufacturers are compelled to use standardised packaging, regardless of the warning design.

Patterns of combustible tobacco use in U.S. young adults and potential response to graphic cigarette health warning labels

In the evolving landscape of tobacco use, it remains unclear how tobacco control efforts should be designed and promoted for maximum impact. The current study links the identification of latent classes of young adult combustible tobacco users with anticipated responses to graphic health warning labels (HWLs). Data were collected in January 2012 using an online address-based panel as part of the Legacy Young Adult Cohort Study, and analyses were conducted in 2013. Latent class analyses identified five groups of tobacco users in a national sample of 4,236 young adults aged 18–34years: (1) little cigar/cigarillo/bidi (LCC) and hookah users (4%); (2) nonusers, open to smoking (3%); (3) daily smokers who self-identify as “smokers” (11%); (4) nondaily, light smokers who self-identify as “social or occasional smokers” (9%); and (5) nonusers closed to smoking (73%). Of the nonusers closed to smoking, 23% may be better characterized as at risk for tobacco initiation. Results indicate differences in the potential effectiveness of HWLs across classes. Compared to the daily “smokers,” LCC and hookah users (RRR=2.35) and nonusers closed to smoking (RRR=2.33) were more than twice as likely to report that new graphic HWLs would make them think about not smoking. This study supports the potential of graphic HWLs to prevent young nonusers from using tobacco products. It suggests that the extension of prominent HWLs to other tobacco products, including LCCs and hookah tobacco, may also serve a prevention function.

Australian smokers’ support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

BackgroundPlain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the...

Compelled Commercial Speech

This paper is the text of the fourth annual C. Edwin Baker Lecture for Liberty, Equality, and Democracy at the West Virginia University College of Law, which will be delivered in November and subsequently published in the West Virginia Law Review. The article explores the burgeoning doctrine of “compelled commercial speech,” with special emphasis on recent decisions of the United States Court of Appeals for District of Columbia Circuit, including American Meat Institute (“AMI”) v. Department of Agriculture, an en banc decision upholding the mandated labeling of meat products; National Association of Manufacturers (“NAM”) v. SEC, which struck down features of SEC mandated reports about the origins of conflict minerals; and R.J. Reynolds Tobacco Co. v. FDA, which invalidated FDA mandated graphic cigarette warnings. Commercial speech doctrine was established in order to protect what Central Hudson called the “informational function” of commercial communications. The object of the doctrine was explicitly to protect the capacity of an audience to receive information rather than to safeguard the autonomy of a commercial speaker. The informational function implies a constitutional asymmetry between restrictions on commercial speech and compelled disclosures of commercial speech. The former impair the distribution of information; the latter enhance it. The tendency of many judges to adjudicate compelled commercial speech cases in light of decisions like West Virginia State Board of Education v. Barnette, which defend the autonomy of speakers within public discourse, is deeply misplaced. The article defends the proposition that First Amendment jurisprudence is plural, not unitary. The Court embraced the plurality of First Amendment jurisprudence in Zauderer v. Office of Disciplinary Counsel, which holds that factual commercial speech can be compelled if it is “reasonably related” to an appropriate government purpose. First Amendment rights of commercial speakers in such circumstances are deemed to be “minimal.” The article discusses the relationship between the Zauderer test for compelled commercial speech and the Central Hudson test for restrictions on commercial speech, which is the object of much unfocused discussion in AMI. Compelled commercial speech, like government speech, is an effort to affect the content of public opinion. Both compelled commercial speech and government speech raise questions about how a democratic government may constitutionally influence the shape of a public opinion to which it is in theory responsive. The article seeks to explain certain doctrinal restrictions on compelled commercial speech in light of constitutional concerns that arise when government seeks to affect the content of public opinion. It offers an analysis of why government efforts to inform public opinion through the required disclosure of facts is constitutionally distinct from government efforts to shape public opinion through the required disclosure of opinions. The article explores how compelled disclosures of opinion may constitutionally be distinguished from compelled disclosures of fact, a distinction that lies at the heart of decisions like NAM and R.J. Reynolds. The article also discusses the kinds of state interests that may justify compelled commercial speech, which is the subject of great dispute in AMI.

Public Policy and Health

Public policies designed to improve health and well-being are challenged by people’s resistance. A social psychological perspective reveals how health policies can pose a psychological threat to individuals and result in resistance to following health recommendations. Self-affirmation, a brief psychological intervention that has individuals focus on important personal values, can help reduce resistance to behavior change and help promote health and well-being in four health-policy domains: graphic cigarette warning labels designed to get people to quit smoking, community health programs targeted at high-risk populations, alcohol intervention and prevention programs targeted at problem drinkers, and adherence to medical recommendations and treatment regimens among people coping with disease. Using self-affirmation has important strengths and limitations as a tool to help policymakers and practitioners encourage better health choices.

The economic value to smokers of graphic warning labels on cigarettes: Evidence from combining market and experimental auction data

Many countries now require prominent pictorial health warning labels (HWLs) on the front and back of cigarette packages. In the US, pictorial HWLs have been adopted, but tobacco industry litigation has delayed their implementation. This intervention could have value to smokers, if it increases their information and changes their smoking behavior. In this paper we estimate the value of two different health warning labels for cigarette packages relative to the current US labeling policy. Our methodology does not depend on the personal values of policy makers or other individuals, as the value of information estimates we derive are based solely on smokers’ own consumption choices, not any public health or other effects. We introduce an approach to valuing information with a surplus measure that couples willingness-to-pay from non-hypothetical experimental auctions with time-series revealed preference demand estimates. We find that a pictorial HWL has a large value to smokers, and a higher value than a label that only contains text, insofar as changing purchase behavior.

Nonsmokers' responses to new warning labels on smokeless tobacco and electronic cigarettes: an experimental study.

BackgroundGraphic warning labels are a tobacco control best practice that is mandated in the US for cigarettes under the 2009 Family Smoking Prevention and Tobacco Control Act. However, smokeless tobacco products are not required to carry graphic warning labels, and as of September 2014, electronic cigarettes in the US carry no warning labels and are aggressively marketed, including with “reduced harm” or “FDA Approved” messages.MethodsIn this online experiment, 483 US adult non-users of tobacco were randomized to view print advertisements for moist snuff, snus, and e-cigarettes with either warning labels (current warning label, graphic warning label) or “endorsements” (a “lower risk” label proposed by a tobacco company, an “FDA Approved” label) or control (tobacco advertisement with no label, advertisement for a non-tobacco consumer products). Main outcome measures included changes in perceived harm, positive attitudes towards, openness to using, and interest in a free sample of moist snuff, snus, and e-cigarettes.ResultsThe graphic warning label increased perceived harm of moist snuff and e-cigarettes. “Lower risk” and “FDA Approved” labels decreased perceived harm of moist snuff and snus respectively. Current warning label and graphic warning label significantly lowered positive attitudes towards e-cigarettes. In this sample of non-users of tobacco, 15% were interested in a free sample of alternative tobacco products (predominantly e-cigarettes). Proportion of participants interested in a free sample did not differ significantly across the conditions, but those interested in a free sample had significantly lower perceptions of harm of corresponding tobacco products.ConclusionsRegulatory agencies should not allow “lower risk” warning labels, which have similar effects to the “FDA Approved” label, which is prohibited, and should consider implementing graphic warning labels for smokeless tobacco products and e-cigarettes.

Public support for graphic health warning labels in the U.S.

In 2009, the U.S. Food and Drug Administration was required to mandate that graphic health warning labels be placed on cigarette packages and advertisements. To assess public support in the U.S. for graphic health warning labels from 2007 to 2012. Data from 17,498 respondents from 13 waves of the National Adult Tobacco Survey, a list-assisted random-digit-dial survey, were used. Overall support for graphic health warning labels, as well as support by smoking status, and by sociodemographics and smoker characteristics are estimated. Analyses were conducted in 2014. Since 2007, a majority of the public overall has been in favor of labels. Support increased significantly among the public overall and among non-smokers from 2007 through 2009 (p<0.001), after which it remained flat. Among smokers, support levels increased from 2007 through 2011 (p<0.001), but decreased significantly from 2011 through 2012 (p<0.001). Support was high regardless of smoking status, although among smokers, support varied by level of smoking, interest in quitting, and whether labels were seen as an important reason to quit. Support varied by sociodemographic characteristics, particularly among smokers. Younger, less-affluent, and less-educated smokers supported labels at higher levels than their counterparts. A majority of U.S. residents support graphic health warning labels for cigarette packs, though support among smokers declined after 2011.

Women's Perspectives on Smoking and Pregnancy and Graphic Warning Labels

To explore women's knowledge, attitudes, and beliefs about adverse outcomes associated with smoking during pregnancy and which outcomes might motivate cessation; to explore reactions to graphic warnings depicting 2 adverse outcomes. Twelve focus groups were conducted with women of childbearing age who were current smokers. Participants had low to moderate awareness of many outcomes and believed it was acceptable to smoke in the first trimester before knowledge of pregnancy. Perceived susceptibility to outcomes was low. Motivators included risk-focused information, especially serious risks to the baby (eg, stillbirth, SIDS). Graphic warnings produced strong reactions, especially the warning with a real photo. Despite barriers to reducing rates of smoking during pregnancy, educational information and photos depicting babies' risks could motivate women to quit.

Do the Ends Justify the Means? A Test of Alternatives to the FDA Proposed Cigarette Warning Labels

Three studies provide empirical, social scientific tests of alternatives to the originally proposed U.S. Food and Drug Administration (FDA) cigarette package warning labels on health risk beliefs, perceived fear, and effectiveness. Our research addresses questions at the root of the legal disputes surrounding FDA regulation of cigarette package warning labels. Specifically, we describe results from three studies that investigate the mediating role of health beliefs and perceived fear in shaping message effectiveness and intentions to quit. The first study featured nonsmoking young adults, while the second and third studies sampled adult daily smokers. Each study was a randomized experiment with five warning-label image conditions: full-color graphic warning labels, black-and-white graphic warning labels, warning text (no graphic image), Surgeon General’s warning labels, and no warning. Results consistently indicate that graphic warning labels (in both color and black-and-white) promote increased perceptions of fear, which in turn are associated with greater (perceived and actual) effectiveness. We conclude with a discussion of the results, highlighting implications, public policy considerations, and suggestions for future research.

Should Australia reconsider its ban on the sale of electronic nicotine delivery systems?

In the past 30 years, steep increases in tobacco taxes, advertising bans, and bans on smoking in public places have reduced the daily smoking rate in Australian adults from 35% in 1983 to 13% in 2013.1,2 Australia was an early adopter of graphic health warnings on cigarette packs and mandatory plain packaging of cigarettes.2 In 2011, Australia joined Brazil, Canada, and several European countries in banning the sale of e-cigarettes or electronic nicotine delivery systems.3

Familiarity undermines the impact of graphic health warnings against smoking

Familiarity undermines the impact of graphic health warnings against smoking