Pictorial Health Warning Labels Research Articles

Pictorial health warning labels on cigarette packages: an investigation on opinions of male smokers.

Background:Health warning labels on cigarette packages are among the most straightforward and important tools to communicate with smokers and various studies have illustrated their efficacy.Objectives:The current study aimed to investigate the opinions of male smokers in Mashhad city about the efficacy of health warning labels printed on cigarette packages on the smoking status of smokers.Patients and Methods:This cross-sectional descriptive study was conducted in 2013 using a questionnaire. The research population included the male smokers of Mashhad. The participants were selected from the customers referring to the newsstands for cigarettes. The obtained data were analyzed employing SPSS software Version 16, and the statistical tests including Kruskal-Wallis, Spearman, and correlation coefficient of Pearson, Chi Square, Mann-Whitney, and Bonferroni correction were used in this regard.Results:In this research, there were 500 participants with the average age of 25 years. The initiation age of smoking was eight years while the maximum age was reported as 45 years. Results of this research about the effect of these labels on decreasing cigarette consumption rate showed that almost half of the participants believed that these labels were ineffective for them (52.2%) and other smokers (53.8%).Furthermore, significant relationship was found between the age and opinion of the smokers about the influence of these labels on reducing their cigarette consumption (P < 0.001).Conclusions:To promote the effect of printed images on cigarette packages, it is recommended to consider the suitability of labels in the targeted culture. In addition, to be more effective consultation sites to quit smoking should be introduced under the images.

Author Response

Drs. de Bruin and Peters raise some interesting points about our article,1 but we disagree with their characterization both of tobacco and communication research in general, and of our specific findings and conclusions. Our conclusions are based on an extensive body of evidence, not only from our own study but also the wider published scientific literature, which consistently has demonstrated the greater effectiveness of pictorial health warning labels (HWLs) over text-only warnings.2

Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment.

BackgroundThe U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups.Methods/FindingsParticipants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22−1.62), and intention to quit (OR = 1.30, 95% CI = 1.10−1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057).ConclusionsFindings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities.

Adult Smokers' Reactions to Pictorial Health Warning Labels on Cigarette Packs in Thailand and Moderating Effects of Type of Cigarette Smoked: Findings From the International Tobacco Control Southeast Asia Survey

Introduction:In this study, we aimed to examine, in Thailand, the impact on smokers’ reported awareness of and their cognitive and behavioral reactions following the change from text-only to pictorial warnings printed on cigarette packs. We also sought to explore differences by type of cigarette smoked (roll-your-own [RYO] vs. factory-made [FM] cigarettes).Methods:Data came from the International Tobacco Control Southeast Asia Survey, conducted in Thailand and Malaysia, where a representative sample of 2,000 adult smokers from each country were recruited and followed up. We analyzed data from one wave before (Wave 1) and two waves after the implementation of the new pictorial warnings (two sets introduced at Waves 2 and 3, respectively) in Thailand, with Malaysia, having text-only warnings, serving as a control.Results:Following the warning label change in Thailand, smokers’ reported awareness and their cognitive and behavioral reactions increased markedly, with the cognitive and behavioral effects sustained at the next follow-up. By contrast, no significant change was observed in Malaysia over the same period. Compared to smokers who smoke any FM cigarettes, smokers of only RYO cigarettes reported a lower salience but greater cognitive reactions to the new pictorial warnings.Conclusions:The new Thai pictorial health warning labels have led to a greater impact than the text-only warning labels, and refreshing the pictorial images may have helped sustain effects. This finding provides strong support for introducing pictorial warning labels in low- and middle-income countries, where the benefits may be even greater, given the lower literacy rates and generally lower levels of readily available health information on the risks of smoking.

Impact of cigarette package health warnings with pictures in Mexico: results from a survey of smokers in Guadalajara

Evaluate the impact of the first pictorial health warning labels (HWLs) on cigarette packs in Mexico. Cross-sectional survey of a representative sample of 1 765 adult smokers from Guadalajara, Mexico, 2010. Logistic regression models were estimated to determine the association between recall of having purchased a pack with a pictorial HWL and psychosocial variables indicating their impact. 58% reported having purchased a pack with one of the pictorial HWLs, and these were considered the exposed population. Exposed smokers reported a greater frequency of thinking about smoking-related risks (34 vs. 25% p=0.003), and thinking about quitting smoking (23 vs. 14% p=0.001). Exposure to pictorial HWLs was also associated with a greater acceptability of HWLs as a means of communicating with smokers (93 vs. 87% p<0.001), as was the perception that the government communicates well about tobacco-related health risks (68 vs. 55% p<0.001). Pictorial HWLs have made smokers think more about these risks and about quitting smoking. This policy should continue to be exploited as a cost-effective educational intervention.

Cigarette Warning Label Policy Alternatives and Smoking-Related Health Disparities

Pictorial health warning labels on cigarette packaging have been proposed for the U.S., but their potential influences among populations that suffer tobacco-related health disparities are unknown. To evaluate pictorial health warning labels, including moderation of their influences by health literacy and race. From July 2011 to January 2012, field experiments were conducted with 981 adult smokers who were randomized to control (i.e., text-only labels, n=207) and experimental conditions (i.e., pictorial labels, n=774). The experimental condition systematically varied health warning label stimuli by health topic and image type. Linear mixed effects (LME) models estimated the influence of health warning label characteristics and participant characteristics on label ratings. Data were analyzed from January 2012 to April 2012. Compared to text-only warning labels, pictorial warning labels were rated as more personally relevant (5.7 vs 6.8, p<0.001) and effective (5.4 vs 6.8, p<0.001), and as more credible, but only among participants with low health literacy (7.6 vs 8.2, p<0.001). Within the experimental condition, pictorial health warning labels with graphic imagery had significantly higher ratings of credibility, personal relevance, and effectiveness than imagery of human suffering and symbolic imagery. Significant interactions indicated that labels with graphic imagery produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery produced greater group differences. Pictorial health warning labels with graphic images have the most-pronounced short-term impacts on adult smokers, including smokers from groups that have in the past been hard to reach.

Linking mass media campaigns to pictorial warning labels on cigarette packages: a cross-sectional study to evaluate effects among Mexican smokers

ObjectiveThis study assessed the effects of pictorial health warning labels (HWLs) and a linked media campaign in Mexico.MethodsCross-sectional data were collected from a population-based sample of 1756 adult smokers, aged...

Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content.

The objective of this study was to determine the most effective content of pictorial health warning labels (HWLs) and whether educational attainment moderates these effects. Field experiments were conducted with 529 adult smokers and 530 young adults (258 nonsmokers; 271 smokers). Participants reported responses to different pictorial HWLs printed on cigarette packages. One experiment involved manipulating textual form (testimonial narrative vs. didactic) and the other involved manipulating image type (diseased organs vs. human suffering). Tests of mean ratings and rankings indicated that pictorial HWLs with didactic textual forms had equivalent or significantly higher credibility, relevance, and impact than pictorial HWLs with testimonial forms. Results from mixed-effects models confirmed these results. However, responses differed by participant educational attainment: didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In the second experiment, with textual content held constant, greater credibility, relevance, and impact was found for graphic imagery of diseased organs than imagery of human suffering. Pictorial HWLs with didactic textual forms seem to work better than those with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.

The Appeal of Smokeless Tobacco Products Among Young Canadian Smokers: The Impact of Pictorial Health Warnings and Relative Risk Messages

Although the health risks from smokeless tobacco (ST) are lower than cigarettes, it remains unclear how smokers might use ST products, including as a substitute, a cessation aid, or concurrently with cigarette use, if at all. Additionally, there is little evidence examining the impact of health warning labels (HWL) on ST use and perceptions. The current study investigated perceptions of ST products with and without HWL and a relative health risk (RHR) message. The study consisted of a full-factorial "between-subjects" experiment in which 3 HWL and a RHR message were systematically varied. Canadian smokers aged 18-30 years (N = 611) completed an online survey where they viewed four brands of ST packages altered according to the experimental conditions. Approximately half of the smokers indicated that they were willing to try ST as a substitute and to help quit smoking. More than one quarter (28%) of smokers were unaware that using ST is less harmful than smoking. Pictorial HWL increased false beliefs about the RHR of ST and decreased smokers' willingness to try ST, whereas text warnings did not. Adding a RHR message communicating the lower risk of ST compared with cigarettes increased willingness to try ST when added to text HWL but decreased willingness to try ST even further when added to pictorial HWL. The findings indicate relatively high levels of appeal for ST among young adult Canadian cigarette smokers. Pictorial HWL reduced the appeal of ST products and increased perceived risks, including the false belief that ST is equally harmful as cigarettes. Further research could consider evaluating designs of HWL on ST products that better balance absolute and RHR.