Pictorial Health Warning Labels Research Articles

Prevalence and predictors of waterpipe smoking cessation among young adults in the US: Findings from a population-based study

BackgroundThe prevalence of waterpipe tobacco (WPT) smoking is 9.2 % among young adults aged 18–24 years in the United State (US). Adequate understanding of the factors predicting WPT smoking cessation among the young population is essential to tobacco control efforts. This study assessed the prevalence and predictors of WPT smoking cessation among young adults. MethodsThe population assessment of tobacco and health (PATH) study data (waves 1–5) was used for the study. A total sample of 561 young adults exclusively using WPT (past 30-days) was used for the analysis. The probability of WPT smoking cessation (no use in the past 12 months) was estimated using the Kaplan-Meier survival method, and the predictors were assessed using the Cox proportional hazards regression model. ResultsDuring the five waves, 25.1 % of the young adult WPT smokers quit smoking. Among them, 58.2 % were females and the remaining 41.8 % were males. The Hispanics (40.2 %) had the highest rate of cessation among the ethnic groups. Regret smoking (adjusted hazard ratio (aHR) = 2.33, 95 % confidence interval (CI) = 1.24–4.36), smoking restriction at home (aHR = 2.86, 95 % CI = 1.41–5.88), and living in Midwest geographical region (aHR = 2.11, 95 % CI = 1.16–3.84) increased the likelihood whereas alcohol use (aHR = 0.62, 95 % CI = 0.41–0.93) decreased the likelihood of cessation among the young adult WPT smokers. ConclusionsCommunicating the health and economic consequences associated with WPT smoking (e.g., pictorial health warning labels), involving smoker’s household members in WPT awareness campaigns, and closing regulatory loopholes related to WPT venues will increase the WPT smoking cessation rate among the young population in the US.

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study

PurposeWaterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with...

The Effects of Pictorial Health Warning Label on Waterpipe (Low- and High-Frequency) Smokers' Experiences, Toxicant Exposures, and Puffing Behavior.

Pictorial health warning label (PHWL) is an effective risk communication measure among cigarette smokers. However, there is a lack of knowledge regarding the effect of PHWL on low- and high-frequency waterpipe (WP) smokers. This study examined the effects of PHWL on puffing behavior, subjective experiences, and toxicant exposures among low- and high-frequency WP smokers in the United States (US). Sixty current (past-month) WP smokers (low-frequency; n = 30 and high-frequency; n = 30) completed two 45-min ad libitum WP smoking sessions in a cross-over design study (WP with no-PHWL vs. WP with PHWL). We compared the mean differences of puff topography, expired carbon monoxide (eCO), plasma nicotine concentration, and subjective experiences between the two smoking groups. Mean age of low-frequency smokers was 21.5years and high-frequency smokers was 21.3years. Compared to high-frequency, low-frequency smokers had significant reduction in average total smoking time [mean difference (SD) = -7.6 (10.2) min vs. -2.6 (6.7) min, p = 0.03] and number of puffs [mean difference (SD) = -33.37 (70.7) vs. -0.70 (29.2), p = 0.02] following exposure to PHWL compared to no-PHWL condition. Post-session subjective experiences were lower among high-frequency smokers compared to low-frequency smokers following smoking WP with PHWL compared to the no-PHWL session (puff liking -1.2 vs. -0.5; puff satisfaction -1.0 vs. -0.3; craving reduction -0.5 vs. 1.2) (p < 0.05 for all). Our findings indicate that placing PHWL on the WP device may be a promising strategy with differential effectiveness among WP smokers: low-frequency (reduce puffing behaviors) and high-frequency (reduce smoking experience).

"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon.

Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories. Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.

Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment.

To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs. For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'. A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)]. Mexico, on-line panel. Adult smokers (n = 705). For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices. Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background. Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

Evaluating the impact of plain packaging among Canadian smokers: findings from the 2018 and 2020 ITC Smoking and Vaping Surveys

BackgroundIn February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75%...

Novel Insights into Young Adults' Perceived Effectiveness of Waterpipe Tobacco-Specific Pictorial Health Warning Labels in Lebanon: Implications for Tobacco Control Policy.

This study aims to explore the perceived effectiveness of waterpipe (WP) tobacco specific health warning labels (HWLs) among young adult WP smokers and nonsmokers in Lebanon. Before participating in focus group discussions, participants (n = 66; WP smokers n = 30; nonsmokers n = 36; age 18–33) completed a brief survey to rate the effectiveness of 12 HWLs’ and rank them according to four risk themes (WP health effects, WP harm to others, WP-specific harm, and WP harm compared to cigarettes). Differences in HWLs ratings by WP smoking status were examined and the top-ranked HWL in each theme were identified. HWLs depicting mouth cancer and harm to babies were rated as the most effective by both WP smokers and non-smokers. WP smokers rated HWLs which depicted harm to children and infants as more effective than non-smokers. The top-ranked HWLs for perceived overall effectiveness were those depicting “oral cancer”, “harm to babies”, “orally transmitted diseases” and “mouth cancer”. HWLs depicting oral lesions and harm to babies were rated as most effective, while HWLs showing the harmful effects of WP secondhand smoke on infants and children were rated as less effective by nonsmokers compared to smokers. Our study provides evidence on the potential effectiveness of HWLs for further evaluation in Lebanon and the Eastern Mediterranean region. The results will inform and guide the development and implementation of tobacco control policy.

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design

BackgroundWaterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.

Industry manipulation of pictorial health warning labels in Pakistan

Approximately 10.5% of adults in Pakistan (about 13 million) smoke cigarettes,1 causing 134 000 deaths annually.2 To reduce the burden of disease, the Pakistan government implemented a requirement in 2010...

Perceived Effectiveness of Pictorial Health Warning Labels of Tobacco Products and Associated Factors among Smokers and Quitters in Kaski District, Nepal

Introduction: Globally, tobacco kills more than seven million people per year. In Nepal, more than fifty different types of tobacco products, both in smoke and smokeless forms, are available. Pictorial health warning labels (PHWLs) on tobacco products provide an effective way to aware both literates and illiterates about the health effects of tobacco use. This study aimed to assess the perceived effectiveness of pictorial health warning labels of tobacco products and associated factors among smokers and quitters.&#x0D; Methods: The study design was community-based cross-sectional analytical with the quantitative method. We interviewed 389 adults (111 Quitters and 278 Smokers) of Kaski district. The sample was taken from both rural and urban areas based on existing household proportion. Ethical approval was taken from NHRC. We entered data in EpiData and analyzed in SPSS softwares. The perceived effectiveness scores of PHWLs were calculated (alpha ranges from 0.91 to 0.96) and compared among different groups using the Wilcoxon rank-sum test and Kruskal-Wallis test with the Dunn’s multiple comparisons. The perceived effectiveness score of PHWLs were correlated with discrete covariates using Spearman rank correlation.&#x0D; Results: Nearly one-third of the participants (32.7%) had bought a single piece of tobacco product, which is not allowed in Nepal. Nearly sixteen percentage of the participants were moderate to high level of nicotine dependent. Only twelve percent of participants wanted to quit or already quitted as s/he saw the PHWLs. Scores of Premature birth was statistically significant (p=0.031) on smoking status. Martial status, ethnicity, any family member use tobacco, age at first exposure psychological response, behavioral response and message credibility were statistically significant for the perceived effectiveness of PHWLs among smokers. Whereas place of resident, education status, age, psychological response, behavioral response, self efficacy and message credibility were statistically significant at p&lt;0.05 for the perceived effectiveness of PHWLs among quitters.&#x0D; Conclusions: This study concluded that premature type of PHWL was more effective than other type of PHWLs. The interventional program along with social and behavior change communication should be focused on the psychological, behavioral related and geographical setting. Further research is suggested to carryout the interventional study addressing behavioral and psychological factors.

The impact of ‘on-pack’ pictorial health warning labels and calorie information labels on drink choice: A laboratory experiment

Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA. Health warning labels reduce hypothetical selection of SSBs in online studies but uncertainty surrounds their impact on selection of drinks for consumption. Calorie information labels are also promising but their impact on SSB selection is unclear. This laboratory study assessed the impact on SSB selection of ‘on-pack’ labels placed directly on physical products: i.a pictorial health warning label depicting an adverse health consequence of excess sugar consumption; and ii.calorie information labels. Potential moderation of any effects by socio-economic position (SEP) was also examined. Participants - 401 adults, resident in England, approximately half of whom were of lower SEP and half of higher SEP, were asked to select a drink from a range of two non-SSBs and four SSBs (subsequent to completing a separate study assessing the effects of food availability on snack selection). The drinks included ‘on-pack’ labels according to randomisation: Group 1: pictorial health warning label on SSBs; Group 2: calorie information label on all drinks; Group 3: no additional label. The primary outcome was the proportion of participants selecting an SSB. Compared to not having additional labels (39%), neither the pictorial health warning label (40%) nor calorie information labels (43%) affected the proportion of participants selecting an SSB. Lower SEP participants (45%) were more likely to select an SSB compared to those of higher SEP (35%), but SEP did not moderate the impact of labels on drink selection. In conclusion, pictorial health warning labels may be less effective in reducing SSB selection in lab-based compared with online settings, or depending on label design and placement. Findings suggest that effects might be absent when choosing from real products with actual ‘on-pack’ labels, positioned in a ‘realistic’ manner. Field studies are needed to further assess the impact of ‘on-pack’ SSB warning labels in real-world settings to rule out the possible contribution of study design factors.

Pictorial health warning labels on the waterpipe device are effective in reducing smoking satisfaction, puffing behaviour and exposure to CO: first evidence from a crossover clinical laboratory study

ObjectivesThis study examined the effect of pictorial health warning labels (HWLs) on the waterpipe (WP) device on smokers’ experience, puffing behaviour, harm perception and exposure to respiratory toxicants.MethodsThirty WP smokers...

Independent or synergistic? Effects of varying size and using pictorial images in tobacco health warning labels

IntroductionLegal challenges have blocked the implementation of large, pictorial health warning labels (HWLs) in the U.S. In light of future legal questions the U.S. Food and Drug Administration may face in proposing alternative HWLs, we examined whether less restrictive HWL versions on the front of packs—smaller HWLs and/or text-only HWLs that do not include pictorial imagery—may be sufficient to promote cognitive and affective outcomes associated with smoking cessation. MethodsWe recruited low-income smokers in two separate experiments through field-based recruitment methods (Study 1, N = 497) or Amazon Mechanical Turk (MTurk) (Study 2, N = 495). In both studies, we randomly assigned participants to a no-HWL control condition or one of four HWL conditions in a 2 (pictorial vs. text-only) × 2 (50% vs. 30% size) between-subjects design. ResultsRelative to text-only HWLs, pictorial HWLs increased negative affect but not risk belief acceptance, cognitive elaboration about smoking harms, or quit intentions. The 50% HWLs increased quit intentions relative to the control condition in both studies. The 50% HWLs also outperformed the 30% HWLs in promoting quit intentions in Study 2. Subsequent analyses revealed that this effect in Study 2 may have been driven by the 50% HWLs strengthening the relationship between risk-related thoughts and intentions, although there was no evidence for this pattern in Study 1. We found no evidence for interaction effects between the pictorial and size manipulations. ConclusionsOur findings suggest that 50% HWLs, whether pictorial or text-only, can encourage low-income smokers to consider quitting under some conditions.

Evaluating health warning messages specific to waterpipe smoking among university students in Jordan.

Health warning messages specific to waterpipe smoking (WPS) have not been tested enough in literature. This study evaluated university students' response to such messages. Specifically, this study (1) assessed the extent to which certain warning messages and pictorial signs motivate participants to quit WPS smoking; (2) identified the best location to place the warning signs of waterpipe as perceived by participants; and (3) assessed participants' intention to quit WPS. A descriptive, cross-sectional design was used to collect data from 397 university students in Jordan using an Internet-based survey. The following data were collected: intentions regarding WPS, response to nine warning messages, and responses to four pictorial signs. The message that had the highest motivation to quit smoking was " WPS during pregnancy can harm your baby" (79.3%), whereas the highest pictorial sign was regarding "Protect your children" (64.2%). Most (69.5%) participants believed that WPS products and accessories should contain warnings, and the best suggested location was the pipe handle (52.4%). Participants who reported quitting WPS and those who had an intention to quit had significantly higher responses to both types of health warning labels (HWLs). Both text-only and pictorial HWLs were found to encourage quitting WPS among university students. Knowing that participants are having an intention to quit mandates extra efforts to make WPS experience less appealing through reminding them regarding its harms. Support is needed by health care providers to put those effective health warning messages in action. Furthermore, providers can use such health warnings in motivating their patients to quit WPS.

Alcohol pictorial health warning labels: the impact of self-affirmation and health warning severity

BackgroundWe examined whether enhancing self-affirmation among a population of drinkers, prior to viewing threatening alcohol pictorial health warning labels, would reduce defensive reactions and promote reactions related to behaviour change. We also examined how health warning severity influences these reactions and whether there is an interaction between self-affirmation and severity.MethodsIn this experimental human laboratory study, participants (n = 128) were randomised to a self-affirmation or control group. After the self-affirmation manipulation was administered, we tracked participants’ eye movements while they viewed images of six moderately-severe and six highly-severe pictorial health warning labels presented on large beer cans. Self-reported responses to the pictorial health warning labels were then measured, including avoidance, reactance, effectiveness, susceptibility and motivation to drink less. Finally, participants reported their self-efficacy to drink less and their alcohol use.ResultsThere was no clear evidence that enhancing self-affirmation influenced any outcome. In comparison to moderately-severe health warnings, highly-severe health warnings increased avoidance and reactance and were perceived as more effective and increased motivation to drink less.ConclusionsThese findings call into question the validity of the self-affirmation manipulation, which is purported to reduce defensive reactions to threatening warnings. We discuss possible explanations for this null effect, including the impact of participants’ low perceived susceptibility to the risks shown on these pictorial health warning labels. Our finding that highly-severe health warnings increase avoidance and reactance but are also perceived as being more effective and more likely to motivate people to drink less will inform future health warning design and have implications for health warning label theory.

Health Literacy and Attention to Cigarette Health Warning Labels among Rural Smokers.

We evaluated the association of health literacy and attention to the pictorial imagery of 9 health warning labels (HWLs) in a tobacco advertisement among rural US smokers. We hypothesized that lower health literacy would be associated with greater visual attention to pictorial portions of HWLs and evaluated the association between health literacy and recall of advertisement elements. Adult smokers from Appalachian Ohio (N = 180) viewed a pictorial HWL encompassing 20% or 33% of a cigarette advertisement while eye tracking software recorded eye movements toward the advertisement. Health literacy was measured with The Short Test of Functional Health Literacy in Adults. Generalized linear regression revealed that every one-unit decrease in health literacy increased viewing time of the pictorial portion of the health warning label by 1.3 percentage points. Logistic regression revealed that the odds of recalling elements of the pictorial portion of the health warning label increased 20% for every one-unit increase in health literacy. Rural smokers with lower health literacy view pictorial portions of health warning labels longer than those with greater health literacy supporting that health literacy is an important consideration in health communications, including future cigarette warning labels.

Visual Attention Patterns Differ by Pictorial Health Warning Label Features.

In this study, we sought to determine how smokers allocate their attention when viewing the 9 cigarette pictorial warning labels (PWLs) proposed by the Food and Drug Administration (FDA), and identify PWL attributes associated with increased attention. Using eye-tracking data from an exploratory within-subject study, we examined smokers' attention (latency, latency duration, and dwell time) to areas of interest (image vs textual warning) for each PWL among 95 daily, non-treatment-seeking smokers (62.1% male, 48.4% white, mean [SD] age = 32.98 [10.14], mean [SD] cigarettes/day = 15.51 [8.43]). We also compared attention measures by PWL message congruency, textual warning location, and participant rankings of effectiveness. Attention measures differed significantly among PWLs (p s < .001) and by features and self-reported effectiveness rankings (p s < .001 - .039). Congruent PWLs, those displaying text across the warning label, and those ranked most effective were associated with sustained attention to image, whereas incongruent PWLs, those displaying left text, and those ranked least effective, were associated with faster and sustained attention to text. Smokers allocated their attention differently across PWLs. Formats and participant effectiveness rankings of PWLs were associated with visual attention patterns, suggesting the importance of these features to the design of potential future PWLs.

Responses to cigarette health warning labels, harm perceptions and knowledge in a national sample of pregnant and non-pregnant women of reproductive age

IntroductionLittle is known about the effectiveness of cigarette health warning labels (HWLs) among U.S. pregnant and non-pregnant women of reproductive age. Our intent was to examine HWL responses by pregnancy status and their associations with knowledge and perceived harm. MethodsWe conducted cross-sectional analyses of first (2013–2014) and second (2014–2015) Population Assessment of Tobacco and Health waves. The sample (N = 19,095) was representative of U.S. women of reproductive age (18–45 years). We examined three HWL responses (seeing HWLs, forgoing cigarettes because of HWLs, likely-to-quit because of HWLs), perceived harm from smoking, and knowledge of health effects to fetuses and others. Weighted logistic regression compared HWL responses by pregnancy status and their associations with perceived harm and knowledge, adjusting for demographics and tobacco use. Results were presented as marginal predicted probabilities. ResultsPregnant smokers were less likely than never-pregnant smokers to report likelihood of quitting (57% vs 67%, p = 0.020). Forgoing cigarettes and likely-to-quit due to HWLs—but not seeing HWLs—were positively associated with perceived harm and knowledge. Pregnant smokers were less likely to have knowledge of fetal harm (83%) than ever-pregnant (91%, p = 0.006) and never-pregnant (92%, p = 0.003) smokers. However, pregnant smokers who reported likelihood of quitting were much more likely to have knowledge of fetal harm than those who did not (93% vs. 67%, p = 0.028). ConclusionsImplementation of HWLs that elicit stronger reactions—such as pictorial HWLs—and increase knowledge of fetal risks is one action to help reduce tobacco use in pregnant and non-pregnant U.S. women of reproductive age.

The Influence of Health Numeracy and Health Warning Label Type on Smoking Myths and Quit-Related Reactions.

Health numeracy helps individuals understand risk information, but limited data exist concerning numeracy's role in reactions to varying types of health warning labels (HWLs) for cigarettes. A nationally representative online panel of adult current smokers received two exposures (1 week apart) to nine HWLs with either text-only or pictorial images with identical mandated text. Following the second exposure, participants (n = 594) rated their beliefs in smoking myths (eg, health-promoting behaviors can undo the risks of smoking) and how much the warnings made them want to quit smoking. Generalized estimating equation regression examined the relation of objective health numeracy and its interaction with HWL type to smoking-myth beliefs and quit-related reactions. Health numeracy was not significantly associated with smoking-myth beliefs; the interaction with HWL type was also nonsignificant. Adult smokers with lower health numeracy had higher quit-related reactions than those with higher numeracy following exposure to HWLs. The type of HWL significantly modified numeracy's associations with quit-related reactions; no significant association existed between text-only HWLs and quit-related reactions, whereas among those who viewed the pictorial warnings, lower numeracy was associated with greater quit-related reactions (β = -.23; p < .001). Lower as compared to higher health numeracy was significantly associated with higher quit-related reactions to HWLs and especially with pictorial HWLs. Health numeracy and HWL type were not associated with the endorsement of smoking myths. The role of health numeracy in effectively communicating risks to smokers warrants thoughtful consideration in the development of tobacco HWLs. Health numeracy plays an important role in an individual's ability to understand and respond to health risks. Smokers with lower health numeracy had greater quit-related reactions to pictorial health warnings than those who viewed text-only warning labels. Development and testing of health warning labels should consider health numeracy to most effectively communicate risk to US smokers.

Perceived Effectiveness of Differing Health Warning Label Messaging Strategies among Adults in the Republic of Georgia: One Size Does Not Fit All.

Background: While pictorial health warning labels (HWLs) are evidence-based, the different messaging strategies are understudied. Methods: We analyzed 2014 national survey data from 1163 Georgian adults to examine: (1) perceived effectiveness of pictorial vs. text-only HWLs; (2) pictorial HWL themes; and (3) correlates of perceived effectiveness of different pictorial themes. Participants were randomized to evaluate the effectiveness of either Set A or Set B of HWLs (each contained half pictorial, half text-only). Results: All but 2 pictorial HWLs were perceived as more effective than text-only. Factor analyses identified one factor among Set A (“benign”) and two in Set B pictorial HWLs (“benign”, “gruesome”). Among Set A pictorial HWLs, correlates of greater perceived effectiveness included being female, rural residence, not having children, and nonsmoker status. Among smokers, correlates included being female and unmarried, fewer smoking friends, and higher quitting importance. Among Set B, 43.8% rated gruesome pictorial HWLs more effective, 12.9% benign more effective, and 43.4% equally effective. Correlates of perceiving benign more effective included fewer smoking friends and higher income. Among smokers, lower income predicted gruesome being perceived as more effective; fewer smoking friends and higher quitting importance predicted perceiving benign as more effective. Conclusion: A variety of pictorial HWL strategies should be used.