Pictorial Warnings Research Articles

The Framework Convention on Tobacco Control (FCTC) and implementation of tobacco control policies: Lessons learned from Indonesia and Thailand

AbstractThe threat that the tobacco epidemic poses to public health underscores the importance of comprehensive tobacco‐related regulation. Despite aiming to reduce the prevalence of smoking, Indonesia still falls short of this goal. In contrast, within the same region, Thailand's achievement in controlling tobacco serves as a potential role model for Indonesia. To understand the issue, we conducted a literature review of the current regulatory framework as well as the implementation of the World Health Organization's Framework Convention on Tobacco Control (FCTC) and MPOWER framework in both countries. The review was supplemented with a Focus Group Discussion and an in‐depth interview with stakeholders in Thailand and Indonesia. This study finds that: (1) Indonesia currently lacks a strong tobacco control policy champion, whereas Thailand has several authorities that focus on the issue; (2) Thailand's tobacco product advertising and promotion and smoking bans are more restrictive compared to Indonesia's policies; and (3) Thailand's policies on tobacco pictorial health warnings, pharmacotherapy, and excise taxes are more extensive than Indonesia's. We recommend that Indonesia ratify the FCTC as the foundation of tobacco control policies while also strengthening and coordinating organizations working on tobacco control, encouraging subnational governments to introduce regulations, and enforce control, as well as improving excise policies to reduce the affordability of tobacco products.

Young adults’ cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study

ObjectiveAlthough cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration’s...

Cross-sectional online survey of the impact of new tobacco health warnings in Colombia

ObjectivesThis study aimed to explore the impact of a new set of six pictorial warnings introduced in 2018.Design and settingUsing a cross-sectional design, we examined awareness of the new warnings...

Effects of Pictorial Health Warnings (PHWs) on Smoking Behavior of Educated Adult Urban Population of Islamabad

Background: This study was conducted to determine the impact of pictorial health warnings (PHWs) on smoking behavior among the adult urban population of Islamabad. Methods: A total of 384 participants were enrolled including students and general public who were interviewed using a pre designed questionnaire. The respondents were approached at their study/work places and enrolled using non-probability convenient sampling technique. The collected data were entered, cleaned and analyzed by using statistical software IBM SPSS Statistics 23.0. Results: Of the total 384, n=241(62.8%) were male while n=143(37.2%) were female and majority of them were aged between 18 to 33 years. The ratio of smokers and non-smokers were n=310 (80.7%) and n= 74 (19.3%) respectively. Of the 310 smokers, 42% had made an attempt to quit smoking after seeing the pictorial health warning on cigarettes’ packs and among them 23% were successful in quitting smoking. Of the total 384, n=293 (76.3%) responded that family environment influence children towards smoking. Similarly, n=126 (32.98%) reported the role of peer pressure in smoking while n=330 (85.98%) participants believed that media have significant role in modifying cultural norms. Conclusion: Over all positive response of pictorial health warnings on cigarettes ’packs was seen for quitting smoking.

Knowledge, Attitude and Behavior Regarding the Hazards of Tobacco Use and Cigarette and Other Tobacco Products Act among Parents Visiting Pediatric Dental Clinic: A Cross-sectional Questionnaire Survey.

Aim“Today's adolescents are tomorrow's citizens.” Tobacco use in children and adolescents is reaching pandemic levels as they are the most vulnerable population to initiate tobacco use. It is well established that most of the adult users of tobacco, start the use of tobacco either in their childhood or adolescence. Parents are the best route to reach a child and can help lead to bring better outcomes for children. Hence, the aim of this study is to assess the knowledge, attitude, and behavior regarding the hazards of tobacco use and Cigarette and Other Tobacco Products Act (COTPA) among the parents visiting pediatric dental clinic.Materials and methodsA cross-sectional survey was conducted using a self-administered questionnaire regarding knowledge, attitude, and behavior regarding the hazards of tobacco use and COTPA law. Samples size of 400 parents of adolescents aged between 10 and 16 years visiting to the department of Pediatrics and Preventive Dentistry were included in the study, data thus obtained was subjected to statistical analysis.ResultsSmoking tobacco product known to the parent population in the present study is cigarette (88.8%) and smokeless tobacco product is pan masala (65.2%). The tobacco health hazard known is cancer by 70.5 and 85.3% parent populations were aware of mandatory display of pictorial health warnings in COTPA law. Strict implementation of COTPA law was opted by 61.8%.ConclusionKnowledge, attitude, and behavior of parents is required to educate and motivate adolescents. Parents have given their positive attitude regarding the strict implementation of COTPA law in India and realize the role of tobacco as a causative factor for health hazards both in children and adults. COTPA law should be made aware for both young and old to educate and motivate and to prevent the use of tobacco in India.How to cite this articleKattimani S, Thimmegowda U, Nagarathna C. Knowledge, Attitude and Behavior Regarding the Hazards of Tobacco Use and Cigarette and Other Tobacco Products Act among Parents Visiting Pediatric Dental Clinic: A Cross-sectional Questionnaire Survey. Int J Clin Pediatr Dent 2022;15(1):47-53.

The role of alcohol packaging as a health communications tool: An online cross-sectional survey and experiment with young adult drinkers in the United Kingdom.

Alcohol packaging is a potentially valuable means of communicating product and health-related information, with growing academic and political interest in its role as a health communications vehicle. An online cross-sectional survey and experiment were conducted with a non-probability sample of 18-35-year-old drinkers in the United Kingdom (n=1360). The survey assessed exposure to, and engagement with, current messaging on packs, and support for displaying product and health-related information. For the randomised experiment, participants were shown, and asked questions about, a vodka bottle with either no warnings (control), small text warnings, large text warnings or pictorial (image-and-text) warnings; the main binary outcome measures were negative product appeal and social acceptability, and positive cognitive and behavioural impact. Two-fifths of the sample rarely or never saw on-pack health-related information, with almost three-quarters rarely or never reading or looking closely at this. There was strong support for displaying a range of product and health-related information (e.g. units, ingredients) on packs. Relative to the control, products with warnings were more likely to be perceived as unappealing and socially unacceptable, and to positively impact alcohol-related cognitions and behaviours. For example, pictorial warnings were 10 times as likely to positively influence cognitions and behaviours (AOR=10.01, 95% CI: 8.09, 17.46). Alcohol packaging could have an important role in delivering health messaging. Large pictorial or text warnings may help counteract the appeal and social acceptability of alcohol products and increase awareness of risks, potentially supporting a reduction in consumption and related harms.

Maintenance of Tobacco Abstinence—Effect of Anti-Tobacco Propaganda (Media) Messages

Anti-tobacco propaganda media (television, radio, print media and internet media) messages promote knowledge regarding the ill effect of tobacco on the human body as well as increase the negative attitude towards tobacco. However, their role in maintaining tobacco abstinence is not explored much. This review summarizes the effect of anti-tobacco propaganda (media) messages on the maintenance of tobacco abstinence; the influence of different types of anti-tobacco propaganda (media) messages on tobacco users and non-users. Tobacco users and recent quitters are not benefiting from these anti-tobacco propaganda and media messages. The graphic pictorial warnings were found to have more influence over increasing knowledge, changing attitude, enhancing quit attempts, quit intentions, and motivation to quit. However, it is also noticed that these anti-tobacco propaganda media messages have a boomerang effect on tobacco users. These media propaganda messages sometimes act as a cue for tobacco users and make them relapse. Many studies in the past have shown that these media messages positively impact the quitting process but, again, remained significant to the first attempt only. Hence, these messages have not been found to be very effective in maintaining tobacco abstinence among tobacco users. The exposure and frequency of the anti-tobacco propaganda (media) messages matter. Pro-tobacco advertisements can neutralize the effect of anti-tobacco propaganda messages. Although, anti-tobacco propaganda (media) messages play a crucial role in modifying tobacco-related behaviour.

Plain packaging and Pictorial Warning in Asia Countries: Where are we?

Worldwide, around 8 million people die yearly due to tobacco usage. Cigarette smoking is the most popular form of tobacco usage. Smoking has linked to many detrimental health effects among adults and adolescents. Recognising the burden of smoking, World Health Organization have implemented various tobacco control strategies under the Framework Convention of Tobacco Control and mPOWER. This includes implementation of plain packaging and pictorial warning. In Asia, only Thailand, Singapore, Turkey, Saudi Arabia, and Israel have implemented plain cigarette pack. However, some countries have made progress to implement plain cigarette pack. Although some countries have not implemented plain pack, implementation of larger pictorial warning serve as a pathway for implementation of plain packaging. Countries with pictorial warning on cigarette pack should ensure it covers at least 50% of pack. Timor Leste has the largest pictorial warning on cigarette pack in the world. In conclusion, only 5 countries in Asia have implemented plain pack and some countries in this region are yet to implement size of pictorial warning according to requirement of World Health Organization. All countries should target to implement standardized pack to denormalise tobacco usage.

"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.

Tobacco Control in Bolivia: Transnational Civil Society Efforts in Securing a Comprehensive Law.

To document the adoption of a comprehensive tobacco control law in Bolivia, a low-income country in South America. Analysis of the Bolivian case study by reviewing news sources, tobacco control legislation, industry websites, and advocacy reports. Application of the Policy Dystopia Model to analyze tobacco industry and health advocacy arguments and action-based strategies. For decades tobacco control progress in Bolivia remained relatively stagnant due to industry interference. In the 2000s and 2010s, Bolivia ratified the WHO Framework Convention on Tobacco Control (FCTC) and implemented a couple of laws that began restricting smoking in public places and tobacco advertising. In 2015, tobacco control civil society emerged with the creation of Fundación InterAmericana del Corazón (FIC) Bolivia, which began coordinating efforts to counter industry interference. Between 2016 and 2020, FIC Bolivia with financial and technical support from international health groups proactively coordinated interministerial meetings, identified and met with key policymakers, and held public educational socialization events to introduce and support a FCTC-based tobacco control bill. Tobacco companies argued to policymakers and the media the bill would result in lost sales/jobs, increase illicit trade and help smugglers profit but only secured minimal changes. In February 2020, Bolivia passed Law 1280, which established 100% smoke-free environments, banned tobacco advertising (except at the point-of-sale), required 60% pictorial health warnings, among others. International financial and technical support combined with proactive advocacy strategies, including identifying and engaging key policymakers, coordinating interministerial meetings, and educating the public can help pass strong tobacco control laws, especially in low-income countries. Low- and middle-income countries struggle to adopt comprehensive tobacco control legislation due to weak state capacity, limited resources, and aggressive tobacco industry interference. This is one of a handful of studies to examine the adoption of a comprehensive tobacco control law in a low-income country, Bolivia. Proactive health advocacy strategies, including identifying and engaging key political allies, helping coordinate interministerial meetings, and aggressively educating and engaging the public can help pass strong tobacco control laws, especially in low-income countries.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial.

BackgroundPictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents’ purchases of sugary drinks for their children in a naturalistic store laboratory.Methods and findingsParents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).ConclusionsPictorial warnings reduced parents’ purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.Trial registrationThe trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

Public Support for Cigarette Pack Pictorial Health Warnings Among US Adults: A Cross-sectional Analysis of the 2020 Health Information National Trends Survey.

The US Food and Drug Administration issued a final rule requiring new warnings for cigarette packages and advertisements. This study examines population-level characteristics of support for-versus neutrality or opposition toward-cigarette pack warnings that use text and images to portray the negative health effects of smoking. We used nationally representative cross-sectional data of US adults age 18 and older from the 2020 Health Information National Trends Survey (n = 3865). Frequencies and weighted proportions were calculated for neutrality toward, opposition to, and support for pictorial warnings across sociodemographics and other predictors. Weighted, multivariable logistic regression examined predictors of being neutral or opposed versus supportive of pictorial warnings. In 2020, an estimated 69.9% of US adults supported pictorial warnings, 9.1% opposed, and 20.9% neither supported nor opposed them. In fully adjusted models, current smokers had almost twice the odds of being neutral or opposed to pictorial warnings as never smokers (odds ratio [OR] = 1.99, confidence interval [CI] 1.12, 3.52). Adults 75 years and older (vs. 18-34) (OR = 0.55, CI 0.33, 0.94) and those with children under 18 in their household (vs. no children) (OR = 0.67, CI 0.46, 0.98) were less likely to be neutral or opposed. In advance of the Food and Drug Administration's implementation of pictorial warnings on cigarette packages, nearly 70% of American adults support this policy. Disseminating information about the effectiveness of pictorial warnings may further strengthen support among current smokers who are less supportive than never smokers. Furthermore, framing messages around the benefits of pictorial warnings for protecting youth may increase public support. While public support for pictorial warnings on cigarette packages is high in the United States, it may increase further after policy implementation and be strengthened by utilizing information campaigns that convey the evidence that pictorial warnings are an effective public health strategy.

Tobacco smoking habits and nicotine dependence among the college students of University of Delhi, India.

ABSTRACTBackground:According to the report on tobacco control in India, tobacco use causes eight to nine lakh deaths annually in India. Tobacco use is on the rise among youngsters especially the college students. The Government of India has made a mandatory display of pictorial health warnings for both smoking and smokeless forms of tobacco products under the Cigarettes and Other Tobacco Product Act, 2003. The objective of the present study was to assess the prevalence of tobacco smoking and to assess nicotine dependence among the college students of the University of Delhi.Methods:A cross-sectional study was conducted among 400 college students of Delhi University from October to December 2019. A semi-structured self-administered questionnaire method was used to collect data on smoking; pictorial warnings and Fragerstrom criteria were used to assess nicotine dependence.Result:Out of the 400 study participants 92 (23%) participants were ever smokers. Among 62 current smokers, the mean age (±SD) of initiation of smoking was 17.3 years (±2.07), median (interquartile range [IQR]) number of cigarettes smoked per day was 3 (2–6), a majority (80.7%) used to smoke after 30 min of waking up in the morning, majority (59.7%) had low nicotine dependence. About half of the past smokers 47% (14 out of 30) and the current smokers 58% (36 out of 62) told that they had no effect of pictorial warning for quitting or decreasing smoking.Conclusion:The present study revealed the tobacco smoking pattern among college students of Delhi. The majority of smokers and non-smokers perceived that pictorial warning is ineffective in driving to quit smoking.

Evaluation of awareness regarding pictorial warning on tobacco packets and its effect on cessation among tobacco users in Lucknow.

Introduction:Tobacco use has been identified as the leading cause of the preventable death worldwide and estimates that it currently causes 5.4 million deaths/year. In fact, India is suffering a phase of tobacco epidemic.Aim:The aim of the study was to evaluate the awareness regarding pictorial warning on tobacco packets and its effect on cessation among tobacco users.Materials and Methods:A study was conducted among 200 patients having tobacco habit, attending the outpatient department of Public Health Dentistry, KGMU, Lucknow. A self-structured questionnaire was made in English and Hindi language, pertaining to demographic details, type of tobacco products used, frequency, duration of tobacco habits, and awareness regarding pictorial warning.Results:Use of multiple tobacco habits was most prevalent 61 (30.5%) across all age groups, majority 185 (92.5%) of subjects had seen the tobacco warnings, and 113 (56.5%) participants had seen both types of warning (pictorial and written warning). One hundred and ten (55%) of subjects said that warning should be on both sides. Eighty-two (41%) study participants had never tried to quit tobacco habits, 43 (21.5%) of participants tried to quit tobacco habits because of peer pressure and 75 (37.5%) subjects said that after seeing a warning on tobacco packets, they will think to quit tobacco habit.Conclusion:Majority of study participants have observed the warnings on tobacco packets and most of them believe that they could recognize and understand warnings. The study participants believe that warnings on tobacco packets create alertness about various deleterious effects of all tobacco habits and help in dropping or give up these habits. Pictographic warnings were more effective than text warnings.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

Gambaran Self Disclosure Remaja yang Mengalami Broken Home Pengaruh Persepsi Peringatan Bergambar pada Kemasan Rokok Terhadap Minat Beli Konsumen Remaja Akhir di Desa Karang Dima Sumbawa Besar

The rapid development of the cigarette industry in Indonesia has caused the number of cigarette consumers to increase. The government issued Minister of Health Regulation No. 28 of 2013, requiring every cigarette manufacturer to include a pictorial warning on every cigarette package whose impact is expected to increase smokers' knowledge and reduce the number of smokers. This is strongly influenced by perceptions and buying interests. This study aims to determine the effect of the perception of pictorial warnings on the buying interests of late adolescent consumers. One of the areas that is the object of research is Karang Dima Village, located in Sumbawa Regency, West Nusa Tenggara Province, Indonesia. Data analysis in this study uses a descriptive quantitative approach, where the sampling technique uses the analysis of the solving formula. The sample in this study amounted to 72 adolescents in the village of Karang Dima. The data were collected using two scales of research instruments: the perception scale and the buying interest scale.The results of this study indicate that the hypothesis (Ho), which states "there is no effect of the perception of warning images on consumer buying interest in Karang Dima's late teens," is accepted. Meanwhile, the hypothesis (Ha), which says "there is no effect of the perception of warning images on consumer buying interest in the village of Karang Dima late adolescence ," is rejected with a sig of 0.139 (&gt; 0.05).

Cigarette Price Increases, Advertising Ban, and Pictorial Warnings as Determinants of Youth Smoking Initiation in Poland.

Europe's Beating Cancer Plan aims to create a "Tobacco-Free Generation" by 2040. To generate meaningful public health policy to achieve this target, we must understand more clearly the determinants of youth smoking initiation. We examine the determinants of cigarette-smoking initiation in Poland using survival analysis techniques and data from four youth smoking surveys: the 2003, 2009, and 2016 Global Youth Tobacco Surveys (GYTS) and the 2019 PolNicoYouth survey (number of person-period observations N = 164 807). Split-population duration models are employed. The hazard of smoking initiation is modeled as a function of cigarette prices, nonprice tobacco-control measures, and socioeconomic variables. Our study finds a negative and significant relationship between cigarette prices and the hazard of smoking initiation in all models (hazard ratio from 0.86 to 0.91). Lower hazards of smoking initiation were also associated with a comprehensive advertising ban (hazard ratio from 0.69 to 0.70) and with the introduction of pictorial warnings (hazard ratio from 0.65 to 0.68). This study concludes that cigarette price increases, such as from higher cigarette excise taxes, could further significantly reduce cigarette youth smoking initiation in Poland. Removing promotional and advertising elements from cigarette packs and making the health warning more noticeable through plain packaging laws would further accelerate the reduction in smoking initiation. The European Union is currently formally reconsidering the Tobacco Tax Directive. This makes this analysis of the impact of cigarette prices on youth smoking initiation both timely and germane. As ever more countries implement standardized cigarette packaging, findings here provide support for this measure that removes advertising elements from the packs and makes the health warning more noticeable.

Cigarette price increases, advertising ban, and pictorial warnings as determinants of youth smoking initiation in Poland

Cigarette price increases, advertising ban, and pictorial warnings as determinants of youth smoking initiation in Poland

A Qualitative Study of Pictorial Health Warnings on Malaysian Cigarette Packs: How Do the Adults Understand Them?

The WHO recommended pictorial health warnings (PHWs) on cigarette packs in 2003 to educate and warn the public of smoking effects. Malaysia too has implemented this policy since 2009. This study explored the public’s understanding of the gazetted PHWs depicted on cigarette packs available in Malaysia. A qualitative study using four focus group discussions (FGDs) was conducted among smokers and non-smokers aged 18–40 in Malacca, Peninsular Malaysia. Thematic analyses were performed using the Atlas Ti version 8.0 software. Six themes have emerged reflecting the public’s understanding of the existing PHWs in Malaysia, namely, (i) awareness and exposures, (ii) recall and attention, (iii) perceived goals, (iv) perceived target groups, (v) attitude in understanding, and (vi) knowledge and meaning of PHWs. All participants were aware of the PHWs depicted on legal cigarettes but not seen on most illicit cigarettes. PHWs were perceived to give awareness and warning about the smoking effects targeting smokers and non-smokers. Participants understood the lung and oral health-related images easily than other body parts such as gangrene foot, miscarriages, etc. Besides enforcement on illicit cigarettes without PHWs, policymakers or relevant authorities should emphasize creating relevant and clear pictorial messages in educating the public to avoid confusion affecting the public’s understanding of the PHWs.

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.