Pictorial Warning Labels Research Articles

Eye tracking outcomes in smoking health warning labels

Graphic health warning label is an advertisement approach to promote greater public understanding on negative health consequences of smoking. A large volume of data has accumulated on the issue of cigarette smoking health warning labels recently, as the number of smokers are yet still growing, reaching 1.1 billion people who smoked every day. This rising in number of smokers were predicted to significantly impact the number of cases to increase directly proportional related to critical disease such as heart disease and stroke. Therefore, a comprehensive strategy needs for efficient tobacco control, an informative communication campaign and strategy such as pictorial disease warning label that have been conducted since 2009. However, justification of the current evidence on relative warning labels effectiveness are still questionable. This study therefore targeted to investigate the abilities of warning labels in informing the negative consequences related with cigarette smoking, through the cutting technology of eye tracking. 30 students had completed this experiment including both smokers and non-smokers in order to directly assess on how the eye movements react towards the graphic stimuli using eye tracking method. Tobii TX300 eye tracker were used for data collection, filtration and analysis, as the device were more detailed and proven to be less bias compared to usual verbal report. Which helping in interpreting human behaviour in obtaining subjects attention. The collected data sets were further analysed using one-way analysis of variance (ANOVA) technique. With the small difference in results of significant value at 2.15 x 10−19 for eye movement event occur between two categories of subjects, shows that their eye activities towards pictorial warning labels are significantly same, as both categories of subjects focused on same part of the image. Pictorial warning labels were believed to be inefficient to continue as a strategy of tobacco control nowadays as the result showed that critical disease images were ineffective in informing the negative consequences related with smoking cessation. The findings indicate that the strategies could be improve besides using pictorial warning labels that have been conducted over a decade.

Higher negative emotions in response to cigarette pictorial warning labels predict higher quit intentions among smokers

BackgroundCigarette pictorial warning labels (PWLs) could produce stronger quit intentions than text-only warning labels (TWLs) due to greater emotional arousal. Yet, it remains unclear whether PWLs that elicit different levels...

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive-findings from the longitudinal EUREST-PLUS ITC Europe surveys.

Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.

Roll-your-own loose tobacco packaging warning labels: a qualitative study using a novel elicitation method

BackgroundMany countries have seen roll-your-own (RYO) loose tobacco use increase, despite policies to reduce smoking prevalence. On-pack pictorial warning labels (PWLs) typically feature general warnings about smoking, and no jurisdictions...

Cigarette Package Warnings for Adult Smoking Cessation - China, 2018.

What is already known about this topic? After the framework convention on tobacco control (FCTC) came into force, the health warnings on cigarette packaging in the mainland of China had been changed in three rounds. But the warning label is still only pure text and without descriptions of specific health consequences caused by tobacco use. What is added by this report? Although there were two rounds of changes from 2010 to 2018, current health warning labels did not work in increasing Chinese smokers’ smoking cessation intention compared with the previous one. Large pictorial warning labels were more effective than the current health warning label in stimulating Chinese smoker’s willingness to quit. What are the implications for public health practice? Pictorial health warnings could play a great role in promoting the realization of the tobacco control goals of Healthy China 2030. Pictorial health warnings should be printed on cigarette packs in the mainland of China as soon as possible.

The Current State of MPOWER Policies in the Republic of Kazakhstan: Data from the Global Adult Tobacco Survey 2014

The Global Adult Tobacco Survey (GATS) is a global study to monitor tobacco use, and evaluate current measures and requisite policies on tobacco control. In this study, the key indicators from GATS Kazakhstan that address six tobacco control policies are assessed. GATS Kazakhstan was a nationally representative household survey of the adult population aged 15 yr or older (n=4425, 52.8% females) implemented in 2014, in all regions of Kazakhstan. A multi-stage, geographically clustered sample design was used to obtain the key indicators of tobacco use and tobacco measures in the country. The sampling weights were employed to ensure real national representation. A household and individual questionnaire were administered through electronic devices. The majority of current tobacco users were cigarette smokers 22.2%. Overall, 19.0% of adults were exposed to secondhand smoke while at work. One third of smokers made a quit attempt in the last 12 months. Only, 74.0% of adults believed that breathing other people's smoke causes serious illness in non-smokers. Almost all current smokers (97.6%) noticed pictorial health warnings on cigarette packages. Over half (58.0%) of the current smokers had thought about quitting, having seen pictorial warning labels. Exposure to any cigarette advertisement, sponsorship or promotion had been experienced by 25.7% of adults, with the highest rate of noticing cigarette advertisements being found in stores where cigarettes are sold (14.0%). Cigarettes were largely affordable for the population. The GATS Kazakhstan results identified tobacco use indicators, as well as existing gaps in tobacco control measures.

Testing the effects of certain versus hypothetical language in health risk messages

ABSTRACTThis paper tests how certainty conveyed through language can be harnessed to enhance the effectiveness of health risk messages. We conducted experiments with low-income, adult smokers (n = 317) and middle schoolers (n = 321) on pictorial cigarette warning labels. We manipulated hypotheticality of risk through verb modality: present tense, may, can, and will. For adult smokers, present tense led to greater health risk beliefs, compared to hypothetical, among adult males but not females. For youth, contrary to what might seem intuitive, the hypothetical may verb was more effective than the present tense language in promoting health risk beliefs, which was associated with reduced susceptibility to use cigarettes. We discuss the findings in relation applications of construal level theory to health communication.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTIONWe conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.METHODSWe systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.RESULTSTwenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.CONCLUSIONSThe systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.

Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses

Background: The Extended Parallel Process Model (EPPM) responses that emerge from spontaneous reactions to cigarette warning labels remain understudied. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions.Methods: U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n = 1838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions.Results: Participants’ responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories.Conclusions: The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial 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.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

ABSTRACTWarning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., “Smoking can kill you”), we examined the impact of adding: (a) text detailing the person’s name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

Pictorial Warning Labels and Memory for Cigarette Health-risk Information Over Time.

Pictorial cigarette warning labels are thought to increase risk knowledge, but experimental research has not examined longer-term effects on memory for health risks named in text. To investigate memory-consolidation predictions that high- versus low-emotion warnings would support better long-term memory for named cigarette health risks and to test a mediational model of warning-label effects through memory on risk perceptions and quit intentions. A combined sample of U.S.-representative adult smokers, U.S.-representative teen smokers/vulnerable smokers, and Appalachian-representative adult smokers were randomly assigned to a warning-label condition (High-emotion pictorial, Low-emotion pictorial, Text-only) in which they were exposed four times to nine warning labels and reported emotional reactions and elaboration. Memory of warning-label risk information, smoking risk perceptions, and quit intentions were assessed immediately after exposures or 6 weeks later. Recall of warning-label text was low across the samples and supported memory-consolidation predictions. Specifically, immediate recall was highest for Low-emotion warnings that elicited the least emotion, but recall also declined the most over time in this condition, leaving its 6-week recall lowest; 6-week recall was similar for High-emotion and Text-only warnings. Greater recall was associated with higher risk perceptions and greater quit intentions and mediated part of warning-label effects on these important smoking outcomes. High-emotion warnings had additional non-memory-related effects on risk perceptions and quit intentions that were superior to text-only warnings. High- but not Low-emotion pictorial warning labels may support the Food and Drug Administration's primary goal to "effectively convey the negative health consequences of smoking." NCT03375840.

A systematic review of the efficacy of alcohol warning labels

Purpose The placement of warning labels on alcoholic beverages is a policy area with renewed interest, yet a strong evidence base regarding the efficacy of text-based or pictorial warning labels has still to emerge. Increased interest by policymakers has spurred research into potential alcohol warning label designs and messages. The purpose of this article is to draw together recearch in the alcohol warnings literature. Design/methodology/approach The current study seeks to review research that has sought to examine the effectiveness of alcohol warning labels. Searches for English-language articles (since 2000) using the terms “alcohol” and “warning label*” were conducted in 2015 across four databases (Web of Science, PubMed, PsycInfo and Cochrane). Articles were included if they empirically assessed the effectiveness and/or design of alcohol warning labels. Only studies that addressed the targeted individual consumer (consistent with downstream social marketing) were included. A narrative analysis approach was used for the 15 articles identified. Findings Findings are reported on five themes covering the design of the warning, starting with the use of imagery or recommendations, followed by a focus on the warning messages and whether they are specific, use signal words and are based on qualitative or quantitative information. Research limitations/implications Overall, there was little consistency in approach and measures, with very limited research having explored the potential of pictorial warning labels. Numerous research gaps are identified; thus, much more research is needed in this area. The evidence base is weak and caution is needed by policymakers regarding the introduction and implementation of alcohol warning labels. Limitations are discussed. Originality/value The review provides a timely up-to-date evaluation of the alcohol warning labels literature that has seen a recent resurgence but has not been critically reviewed.

Effects of Large Cigarette Warning Labels on Smokers' Expected Longevity.

Smokers underestimate the health risks of smoking and overestimate their expected longevity. Warning labels on cigarette packs might help correct these misperceptions. We carried out an online study with 1200 smokers (18-62 years old), randomized to 3 conditions: text warning labels, pictorial warning labels, and a control group (water bottle labels). Warning labels were based on those proposed by the US Food and Drug Administration in 2010. Participants in each condition saw 4 randomly selected labels and rated their expected longevity and chances of surviving to age 75 after exposure. Analyses of covariance controlled for cigarettes per day and self-rated health. Compared to control, both text and pictorial warnings reduced participants' expected longevity (text: mean = 76.8 years, pictorial: 77.3, control 79.4) and their estimated chances of living to 75 (text: 62.0%, pictorial: 63.0%, control 66.5%). The contrast between text and pictorial labels combined and control showed significantly reduced expected longevity (p = .011) and chances of living to 75 (p = .004). Differences between text and pictorial conditions were not statistically significant. Large text or pictorial warnings on cigarette packs might help smokers develop a more accurate understanding of the effects of smoking on their longevity.

Pictorial warning labels in Jordan: are we maximizing the benefit for smokers?

Pictorial warning labels in Jordan: are we maximizing the benefit for smokers?

Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption.

Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit. Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings. Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking. Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy. Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.

Policy options for extending standardized tobacco packaging.

Smoking is a public health problem that will cause 1 billion deaths in the 21st century, if current smoking patterns persist. (1) Tobacco companies' aggressive marketing has fostered tobacco use by creating brands and linking these to attributes and identities that users and susceptible non-users value. Although many countries now restrict traditional marketing media, tobacco companies have developed increasingly creative strategies to encourage experimentation with tobacco among non-users and deter quitting among users. Packaging has provided an important and until recently, largely unregulated, conduit for these marketing messages and has communicated appealing imagery to young people while using known and familiar brand symbols to reassure existing tobacco users. The World Health Organization's Framework Convention on Tobacco Control (FCTC) (2) obliges Parties to address tobacco packaging. Implementation guidelines for Articles II (3) and 13 (4) include consideration of plain packaging and recognize the myriad ways in which tobacco companies have used packaging to promote tobacco use. In response, Australia, France, Georgia, Ireland, New Zealand, Norway and the United Kingdom of Great Britain and Northern Ireland have either introduced or will soon be introducing standardized or plain packaging. Hungary, Romania, Slovenia and Thailand have already passed legislation to introduce plain packaging, and several other countries (including Belgium, Canada, Chile, Singapore and Sri Lanka, among others) are formally considering this policy. Plain packaging replaces the attractive brand livery displayed on tobacco packs with an aversive colour and standardized text, and is typically combined with larger pictorial warning labels, if these are not already in place. The policy recognizes that on-pack brand imagery has positioned tobacco use as an aspirational behaviour and fostered uptake among young people, (5) transforming tobacco packages from attractive display items to highly unappealing articles. Evidence from Australia shows standardized packaging and larger pictorial warning labels have reduced smokings appeal among young people, (6) increased demand for cessation support and decreased smoking prevalence. (8) Evaluations confirm predictions from experimental and other studies used to support the introduction of this policy. (8) Despite the intuitive logic of using packaging to deter rather than facilitate experimentation with tobacco products, other countries have been cautious in following Australia's approach. The time taken for plain packaging to be more widely adopted and implemented in other countries has caused some frustration among public health researchers and advocates. Nevertheless, this time lag has also provided an opportunity to examine how tobacco companies have reacted to Australia's new policy environment, and to consider whether and where Australian legislation could be extended. We suggest that countries planning to introduce standardized packaging have an opportunity to innovate in at least four ways: (i) restricting or banning brand variant names; (ii) developing larger and more salient onpack warnings; (iii) requiring tobacco products themselves to use dissuasive colours; and (iv) using packaging to create cessation portals that direct tobacco users to quit support. First, the introduction of standardized packaging in Australia saw a rapid increase in brand variant names (or descriptors) such as Marlboro Silver Fine Scent, Winfield Optimum Crush Sky and Peter Stuyvesant New York Blend. (9) These variant names attempt to recreate connotations formerly aroused by visual brand imagery and aim to reassure smokers, deter quitting and potentially attract new users. Recent work suggests the more descriptors used, the more attractive a pack appears. (10) Variants potentially mislead users by linking tobacco to appealing attributes or by minimizing the harm caused by tobacco use and serve no purpose other than to create marketing appeals. …

Informing tobacco control policy in Jordan: assessing the effectiveness of pictorial warning labels on cigarette packs

BackgroundPictorial warning labels (PWLs) deter initiation and motivate quitting. Assessing PWLs is important to track effectiveness and wear out. Jordan introduced an updated set of PWLs in 2013. This study assessed the effectiveness of the set after 2.5 years on the market.MethodsWe administered a survey in a cross-sectional sample of young adults aged 17–26 years. For convenience, respondents were recruited on university campuses. For heterogeneity, respondents were solicited from the different schools in four geographically diverse university campuses. The study compared perceptions of effectiveness surveyed in 2015 to perceptions gauged in 2010 during a pre-launch evaluation exercise. Outcomes of interest were: salience, fear evocation, adding information, and ability to motivate quitting smoking (for smokers) or deterring starting (for non-smokers).ResultsResults indicate awareness of the set among smokers and non-smokers, and their recall of at least one PWL message. Results also indicate effectiveness of the set: (1) 1/3 smokers who frequently saw them reported PWLs to trigger considering quitting, (2) and among both smokers and non-smokers the set in 2015 sustained ability to motivate quitting and staying smoke-free. However, results uncover erosion of salience, suggesting that the set has reached its end of life. Finally, results reveal variability in performance among PWLs; the one PWL that depicts human suffering significantly outperformed the others, and its ability to motivate was most strongly associated with its ability to evoke fear.ConclusionBased on the early signs of wear-out (i.e. erosion of salience), and understanding the importance of sustaining upstream outcomes (especially fear evocation) to sustain motivation, we recommend retiring this set of PWLs and replacing it with a stronger set in line with proven standards.

Assessing Health Impacts of Pictorial Health Warning Labels on Cigarette Packs in Korea Using DYNAMO-HIA.

ObjectivesThis study aimed to predict the 10-year impacts of the introduction of pictorial warning labels (PWLs) on cigarette packaging in 2016 in Korea for adults using DYNAMO-HIA. MethodsIn total, four scenarios were constructed to better understand the potential health impacts of PWLs: two for PWLs and the other two for a hypothetical cigarette tax increase. In both policies, an optimistic and a conservative scenario were constructed. The reference scenario assumed the 2015 smoking rate would remain the same. Demographic data and epidemiological data were obtained from various sources. Differences in the predicted smoking prevalence and prevalence, incidence, and mortality from diseases were compared between the reference scenario and the four policy scenarios. ResultsIt was predicted that the optimistic PWLs scenario (PWO) would lower the smoking rate by 4.79% in males and 0.66% in females compared to the reference scenario in 2017. However, the impact on the reduction of the smoking rate was expected to diminish over time. PWO will prevent 85 238 cases of diabetes, 67 948 of chronic obstructive pulmonary disease, 31 526 of ischemic heart disease, 21 036 of lung cancer, and 3972 prevalent cases of oral cancer in total over the 10-year span due to the reductions in smoking prevalence. The impacts of PWO are expected to be between the impact of the optimistic and the conservative cigarette tax increase scenarios. The results were sensitive to the transition probability of smoking status. ConclusionsThe introduction of PWLs in 2016 in Korea is expected reduce smoking prevalence and disease cases for the next 10 years, but regular replacements of PWLs are needed for persistent impacts.

Do Plain Packaging and Pictorial Warnings Affect Smokers' and Non‐Smokers' Behavioral Intentions?

This research considers how tobacco warnings, plain packaging, and interactions between these measures affect behavioral intentions. While existing literature shows the superiority of pictorial warning labels (PWLs) vs. text‐only tobacco warnings, few studies have examined the interaction effects of warnings and plain packaging on smoking intentions. Nor has earlier work examined the influence of smoking status (smoker vs. non‐smoker) on both warning and plain packaging effectiveness. Our experimental study addressed this gap by surveying 338 individuals using a factorial design with two manipulated factors (PWLs vs. text‐only warnings; plain pack vs. current branded tobacco pack). Results show that the plain pack and warnings work independently and in unison to influence smokers' and non‐smokers' behavioral intentions. The findings are particularly relevant to the many countries currently considering plain packaging and facing opposition from tobacco companies.