Surgeon General's Warning Research Articles

Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics

New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs. A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING"). Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word. New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

Do Young Adults Attend to Health Warnings in the First IQOS Advertisement in the U.S.? An Eye-Tracking Approach.

In October 2019, a heated tobacco product (HTP) IQOS debuted in the United States. This study examined young adults' attention and cognitions in response to an IQOS ad that carried two mandated textual health warnings (Surgeon General's warning and nicotine warning), and how their vaping and smoking status may interact with attention patterns to affect attitude and intention to use IQOS. In November 2019, college students (N = 164) viewed IQOS' first U.S. magazine ad and two distractor ads. Viewing patterns were recorded with eye-tracking. Masked recall and aided recognition, attitude and intention towards IQOS use were later assessed with self-report. Ordinary Least Squares (OLS) regressions and moderated mediation analyses examined the associations between visual attention and viewers' cognitions about IQOS use. Promotional content attracted significantly more attention compared to the warnings. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. For ever-vapers, greater attention allocation to the promotional content in the IQOS ad was associated with more favorable attitude toward IQOS use, which was in turn positively associated with intention to use IQOS. Attention allocation to the warnings did not affect attitude or intentions, regardless of tobacco use status. The results revealed the effects of IQOS promotional content overshadowed the two health warnings in influencing young people's attitude and intention to use IQOS. Young adults who vaped were more vulnerable to HTP advertising with respect to future use and vaping may be a gateway to HTP use. This is the first eye-tracking study examining attention and cognitions associated with the new IQOS ad exposure among young adults. Promotional content in the ad attracted significantly more attention than the two warnings combined. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. Greater attention allocation to the promotional content led to a more favorable attitude toward IQOS use which was associated with increased intention to use IQOS for ever-vapers. However, greater attention allocation to the warnings did not affect attitude or intentions to use IQOS.

Impact of Pictorial Cigarette Warnings Compared With Surgeon General's Warnings on Understanding of the Negative Health Consequences of Smoking.

The Family Smoking Prevention and Tobacco Control Act requires cigarette packages and advertisements to bear health warnings with "color graphics depicting the negative health consequences of smoking." This study assessed whether new US Food and Drug Administration developed pictorial cigarette warnings (PCW) increased understanding of smoking-related risks relative to the current Surgeon General's (SG) warnings. In March-May 2019, adolescent and adult smokers and nonsmokers participated in an online experiment with three sessions completed over approximately 2 weeks. Participants viewed 1 of 16 PCW (treatment conditions) or an SG warning (control) on mock cigarette packages and advertisements. Measures assessed whether warnings provided new information, induced thinking about risks, changed smoking-related health beliefs, and were accurately recalled, among other outcomes. The majority of PCW (≥13 conditions) resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks; they were viewed as more informative, understandable, and attention-drawing compared with the control condition. Most participants believed the warning were factual, although 8 PCW were perceived as less factual than the control. There were changes toward more agreement with health beliefs for 11 PCW between Sessions 1 and 2 and 7 PCW between Sessions 1 and 3. Participants in all treatment conditions were more likely than control condition participants to correctly recall the warning. Across outcomes, PCW related to addiction, death, and quitting did not perform as well as other PCW. Many of the PCW tested increased understanding of the risks associated with cigarette smoking relative to current SG warnings. The Tobacco Control Act requires cigarette packages and advertisements to bear PCW depicting the negative health consequences of smoking. This study tested whether any of 16 newly proposed PCW increased understanding of smoking-related risks relative to existing SG warnings. Results suggest that most PCW tested, particularly those related to less widely known health effects, resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks compared with SG warnings. These results, along with other factors, informed the US Food and Drug Administration's selection of proposed PCW.

Using graphic warning labels to counter effects of social cues and brand imagery in cigarette advertising.

Exposure to cigarette advertising can increase the likelihood of youth smoking initiation and may encourage people who already smoke to continue. Requiring prominent, graphic warning labels could reduce these effects. We test whether graphic versus text-only warning labels in cigarette advertisements influence cognitive and emotional factors associated with youth susceptibility to smoking and adult intentions to quit. We conducted two randomized, between-subjects experiments with middle-school youth (n = 474) and adult smokers (n = 451). Both studies employed a two (graphic or text-only warnings) by two (advertisements with social cues or brand imagery) factorial design with a fifth, offset control group (social cue advertisements with the current US Surgeon General's Warning). Graphic warnings outperformed text-only warnings in reducing visual attention to the advertisement, generating visual attention to the warning and arousing more negative affect. Graphic warnings also reduced the appeal of cigarette brands among youth relative to social cue advertisements with the Surgeon General's warnings. None of the warnings (graphic or textual) influenced health risk beliefs. Graphic warning labels on cigarette advertisements appear to have effects similar to those observed on cigarette packs in previous work, with an added benefit of reducing cigarette brand appeal among youth.

Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial.

Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. To assess the effect of adding pictorial warnings to the front and back of cigarette packs. This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General's warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act's required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General's warning. Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. clinicaltrials.gov Identifier: NCT02247908.

The rise and fall of the nation's doctor Surgeon General's Warning: How Politics Crippled the Nation's Doctor Mike Stobbe University of California Press, 2014. 393 pp.

The rise and fall of the nation's doctor <b>Surgeon General's Warning: How Politics Crippled the Nation's Doctor</b> <i>Mike Stobbe</i> University of California Press, 2014. 393 pp.

TCORS set to support the FDA's regulatory role: Program designed to generate tobacco‐related research to inform policy

TCORS set to support the FDA's regulatory role: Program designed to generate tobacco‐related research to inform policy

Interpretations of Cigarette Advertisement Warning Labels by Philadelphia Puerto Ricans

This study examined Philadelphia Puerto Ricans' interpretations of the Surgeon General's warnings that appear on cigarette packaging and in advertisements. In-home family focus groups in which participants were asked to comment on magazine cigarette advertisements showed a great variety of interpretations of the legally mandated warning labels. These findings (a) corroborate and add to research in public health and communications regarding the possibility of wide variations in message interpretations and (b) support the call for public health messages to be carefully tested for effectiveness among different social groups. The article's focus on Puerto Ricans addresses the problem of misleading conclusions that can arise from aggregating all Latino subpopulations into one group. The use of a naturalistic setting to examine interpretations of messages about smoking departs from the experimental methods typically used for such research and provides new evidence that even a seemingly straightforward message can be interpreted in multiple ways. Understanding and addressing differences in message interpretation can guide public health campaigns aimed at reducing health disparities.

Web sites selling cigarettes: how many are there in the USA and what are their sales practices?

OBJECTIVESTo estimate the number and geographic location of web sites selling cigarettes in the USA, and to examine their sales and marketing practices.METHODSComprehensive searches were conducted using four keyword terms...

A Comparison of the Advertising and Accessibility of Cigars, Cigarettes, Chewing Tobacco, and Loose Tobacco

Background. Tobacco products were compared in regard to their price, point-of-purchase advertising, accessibility to shoplifters, and rate of sale to minors.Methods. An experimental design compared the rates of illegal sales to minors of cigarettes, chewing tobacco, and cigars. Observational surveys of 102 stores measured the number of advertisements for four tobacco products, the manner in which products were displayed, and their accessibility to shoplifters.Results. Illegal sales rates were similar for cigarettes, chewing tobacco, and cigars. Cigars were the least expensive. Cigarettes were the most heavily advertised product, followed by chewing tobacco, cigars, and loose tobacco. Cigarettes were the most accessible to shoplifters. All types of tobacco products were displayed to permit the package to serve as advertising.Conclusions. Point-of-purchase advertising for cigars may be increasing, and their lower price makes them more affordable to youths. Food and Drug Administration regulations that limit point-of-purchase advertising for tobacco products should be expanded to include cigars. Manufacturers pay retailers for the placement of product displays that allow the package to be used as an advertisement without the appearance of the Surgeon General's warning. Generic packaging may be necessary to protect children from point-of-purchase advertising.

Low-Tar Cigarettes Come Under Fire

THE ILLUSION that low-tar brands are safer than regular cigarettes is all smoke and mirrors. A new population-based study has confirmed laboratory evidence that tar and nicotine levels do not predict smokers' exposure to carbon monoxide or the tobacco metabolite cotinine ( Am Rev Respir Dis . 1993;148:435-440). Coalition on Smoking and Health is hoping the new evidence moves the Food and Drug Administration (FDA) and Federal Trade Commission (FTC) to acknowledge that the so-called low-yield cigarettes are being deceptively marketed as though they are less of a health hazard than regular cigarettes, and therefore are subject to regulation as drugs under the Food, Drug, and Cosmetic Act. tobacco industry insists that it does not promote low-yield brands as healthier. The only health claims on any pack of cigarettes or any cigarette advertisements are those made by the Surgeon General's warning, says Phillip Morris spokesperson Sheila Banks-McKenzie. RJ Reynolds' public

Caution: Alcohol advertising and the surgeon general's alcohol warnings may have adverse effects on young adults

Abstract Government mandated warnings are becoming more common. However, studies have not compared the effect of warnings, meant to increase perception of risk, to advertising, which aims to decrease perceptions of risk and enhance perceptions of product benefits. We conducted an experiment to test the effects of the newly introduced Surgeon General's alcohol warnings and advertisements on college students. Surprisingly, the warnings boomeranged, causing drinkers to perceive greater benefits from the alcoholic beverages. The advertisements had powerful effects on both drinkers and nondrinkers, increasing perceptions of benefits and decreasing risks. In part, the ads worked by causing people to perceive fewer risks communicated by the stimulus materials, and reducing people's ability to recall the content of the warning. The results suggest that, for young people, the warning labels in their present form may be counterproductive, and advertisements make drinking more attractive. Implications for warning an...

Manufacturer of 'Death Cigarettes' Says He's Working to Bring About the Death of Smoking

FINALLY there's a cigarette for people who can accept the addictive, carcinogenic, atherogenic, teratogenic, and other toxic effects of smoking—but who just can't tolerate being lied to. By its very name, the manufacturer of "Death Cigarettes" forthrightly declares what is being sold. No virile cowboys, slim-legged, "liberated" beauties, or supercool camels or penguins endorse this brand. The maker of what appears to be the first antismoking cigarette prefers to fly the Jolly Roger on its packaging and promotional materials. In case the skull and crossbones isn't a clear enough message, the cigarette maker has added a written warning (in addition to the required US Surgeon General's warning): "MANUFACTURER'S ADVICE: Cigarettes Are Addictive And Debilitating. If You Don't Smoke, Don't Start. If You Smoke, Quit." "Business is excellent," says Charles Southwood, the founder and owner of Death Tobacco in Venice, Calif, the fledgling company that produces Death Cigarettes. "We are expanding

Manufacturer of 'death cigarettes' says he's working to bring about the death of smoking

FINALLY there's a cigarette for people who can accept the addictive, carcinogenic, atherogenic, teratogenic, and other toxic effects of smoking—but who just can't tolerate being lied to. By its very name, the manufacturer of "Death Cigarettes" forthrightly declares what is being sold. No virile cowboys, slim-legged, "liberated" beauties, or supercool camels or penguins endorse this brand. The maker of what appears to be the first antismoking cigarette prefers to fly the Jolly Roger on its packaging and promotional materials. In case the skull and crossbones isn't a clear enough message, the cigarette maker has added a written warning (in addition to the required US Surgeon General's warning): "MANUFACTURER'S ADVICE: Cigarettes Are Addictive And Debilitating. If You Don't Smoke, Don't Start. If You Smoke, Quit." "Business is excellent," says Charles Southwood, the founder and owner of Death Tobacco in Venice, Calif, the fledgling company that produces Death Cigarettes. "We are expanding

Warnings in Tobacco Advertisements: Marlboro Man vs Surgeon General-Reply

In Reply.— Dr Alwitt fails to understand or has ignored the central issue in our research. The essential context for the warning must be the tobacco advertisement itself. Only 8% of the viewing time was devoted to the warning, while 92% was devoted to the advertisement. Comparisons with advertisements for products that carry no warnings are irrelevant. As we acknowledged in the article, the sample size is small. However, our study remains one of the largest ever reported in the literature using eye tracking techniques. Furthermore, it is the only published study to examine the effectiveness of the Surgeon General's warning for adolescents. Dr Alwitt is incorrect in her statement that the subjects should have been able to read the warning in three visual fixations. The reference 1 that she cites, in fact, states that only eight letters are seen in the average fixation. The warnings on cigarette advertisements average

The Warnings on Cigarette Packages Are Ineffective

To the Editor. — Both smokers and non-smokers regularly encounter the Surgeon General's warnings about the health hazards of tobacco. The presence of these warnings has become a basis for tobacco companies' defense in product liability cases. They have argued that because of these health messages, the public is adequately warned about the alleged hazards of tobacco use. Yet, at the same time, they contend that smoking does not cause disease. There is growing concern that the Surgeon General's warnings may be ineffective. Recent evidence1,2has demonstrated that the warnings are often not seen when they appear on magazine advertisements, billboards, and taxi signs. We conducted a pilot study to examine the public's knowledge of the current Surgeon General's warnings on cigarette packages. In particular, we were interested in the level of knowledge that smokers had about the warnings. Study.— Using a typical market survey format, adults in a

The Surgeon General's Warnings in Outdoor Cigarette Advertising

Outdoor advertising media represent a major vehicle by which cigarette companies promote their products. We investigated the readability of the Surgeon General's warning in cigarette advertisements (ads) in two outdoor media: billboards and taxicab ads. In an experiment in metropolitan Atlanta under typical driving conditions, observers were able to read the entire health warning on 18 (46%) of 39 street billboards but on only two (5%) of 39 highway billboards. In contrast, the content of the ads (ie, brand name, other wording, and notable imagery) could be recognized under the same conditions on more than 95% of the billboards. In a similar study of 100 taxicab cigarette ads in New York City, observers were unable to read the health warning in any of the ads but were able to identify the brand name in all ads and notable imagery in 95% of the ads. Significant differences between the readability of the warning and identification of the advertising content persisted even when partially read warnings were considered to have been read. We conclude that the Surgeon General's warning is not readable in its current form in the vast majority of billboard and taxicab ads. Factors contributing to unreadability include the small size of the letters, the excessive length of the warnings, the distance between the viewers and the ads, and movement between the viewers and the ads.

The Surgeon General's warnings in outdoor cigarette advertising. Are they readable?

The Surgeon General's warnings in outdoor cigarette advertising. Are they readable?