Text-only Warnings Research Articles

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

Responses of young adults to graphic warning labels for cigarette packages

BackgroundIn 2010, the US Food and Drug Administration (FDA) proposed a series of 36 graphic warning labels for cigarette packages. We sought to evaluate the effects of the labels on...

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.

Reactions of Nepali Adults to Warning Labels on Cigarette Packages: A Survey with Employee and Medical Students of a Tertiary Care Medical College of Western Region of Nepal

For the past 30 years, there have been no changes in the text-only cigarette warning labels in Nepal. During this same time period, other countries placed large graphic warning labels on cigarette packages. The purpose of the current study was primarily to compare the differences in reactions to different types of warning labels on cigarette packages, with a specific focus on whether the new warning label adopted by WHO FCTC was better than the text only label used by Nepal. This study was conducted in Gandaki Medical College Teaching Hospital (GMCTH) in 2012, in a tertiary care hospital located in the western region of Nepal. Eligible study participants included in this survey were those aged 18 years and over and those who are studying MBBS/Nursing or who were employees of GMCTH. 500 participants finished the survey. Participants were shown nine types of warning labels found on cigarette packages.They comprised one text only warning label used within Nepalese market and eight foreign brand labels. Participants were asked about the impact of the warning labels on: their knowledge of harm from smoking, giving cigarettes as a gift, and quitting smoking. On comparing the Nepalese warning label with other foreign labels with regards to providing knowledge of harm warning, impact of quitting smoking and giving cigarettes as a gift, the overseas labels were found to be more effective. Both smokers and non-smokers thought that warning labels with text plus graphics were substantially more of a deterrent than text-only labels. The findings from this study support previous research that has found that text-plus graphic warning labels were more salient and potentially more effective than text-only labels.Warning labels are one of the component of comprehensive tobacco control and smoking cessation efforts. Stronger warnings on cigarette packages need to be part of a larger Nepalese public health educational efforts.

The effect of plain cigarette packaging on attention to hea»warnings

BackgroundWhile the Australian Government pushes ahead with the introduction of standardised packaging for tobacco products, the UK Government completed a consultation on this issue in August, 2012. There are several potential benefits, including scope for increasing the effectiveness of health warnings. A recent review suggests that standardised packaging increases the salience of health warnings. Notably, however, the review identified only one study using the most direct measure available to investigate attention: eye movements. The sharpest vision is produced by the central retina, so we use rapid (saccadic) eye movements to fixate on different parts of an image and accrue visual information. By use of eye tracking technology commonly used in psychological research to record eye movements, fixation times on different areas of an image can be calculated as a proxy for attention. Branding is of course designed to be eye-catching, taking advantage of our eyes' tendency to seek areas of high image contrast. Consistent with this fact, removal of branding in the aforementioned study increased the number of saccades towards health warnings, at least for non-smokers or non-daily smokers. However, this result was obtained with graphic warning labels whereas, in the UK, front-of-pack warnings are text only. We aimed to examine the effect of plain packaging on text health warnings by presenting participants with a mocked-up display of branded and plain packaged cigarette packs and asking them to select a pack for purchase. Methods28 adults were recruited by convenience sampling (six men, age 18–40 years, mean age 23·29 years), and consisted of daily (n=9), weekly (n=7), non (n=8), and ex (n=4) smokers. Participants viewed displays containing six packets of cigarettes, with each of the two current UK text health warnings present on three packets. Displays always contained the same six brands, but brand position and assignment of the health warnings was randomised in every trial. Each participant received six consecutive presentations, which alternated between all branded and all plain displays (with order counterbalanced across participants). A mouse pointer appeared 5 s after display onset to allow brand selection, which also ended the trial. A video eye tracker recorded eye movement data. The key measure was the proportion of time participants spent fixating health warnings compared with the rest of the packet, which was either plain or contained the branding. FindingsAs expected, most time was spent looking at branding. Crucially, however, fixation times on warning labels increased in the unbranded compared with the branded presentations (18·1%vs 15·8%). This difference was not uniform across the experiment, but rather was significant only in the first pair of trials (paired-sample t test, p=0·043). InterpretationThe finding suggests that in contexts without recent habituation to warning labels (eg, first-time smokers) plain packaging helps to redirect the eyes towards text-only health warnings. However, the effect appears transient relative to that obtained with graphic warnings. Hence we suggest that a change to plain packaging might be most profitable if accompanied by a shift to front-of-packet graphic warning labels. FundingNone.

Graphic Warning Labels in Cigarette Advertisements: Recall and Viewing Patterns

The Family Smoking Prevention and Control Act gave the U.S. Food and Drug Administration (FDA) legal authority to mandate graphic warning labels on cigarette advertising and packaging. The FDA requires that these graphic warning labels be embedded into cigarette advertising and packaging by September 2012. The aim of this study was to examine differences in recall and viewing patterns of text-only versus graphic cigarette warning labels and the association between viewing patterns and recall. Participants (current daily smokers; N=200) were randomized to view a cigarette advertisement with either text-only or graphic warning labels. Viewing patterns were measured using eye-tracking, and recall was later assessed. Sessions were conducted between November 2008 and November 2009. Data analysis was conducted between March 2011 and July 2011. There was a significant difference in percentage correct recall of the warning label between those in the text-only versus graphic warning label condition, 50% vs 83% (χ(2)=23.74, p=0.0001). Time to first viewing of the graphic warning label text and dwell time duration (i.e., time spent looking) on the graphic image were significantly associated with correct recall. Warning labels that drew attention more quickly and resulted in longer dwell times were associated with better recall. Graphic warning labels improve smokers' recall of warning and health risks; these labels do so by drawing and holding attention.

Graphic Gambling Warnings: How they Affect Emotions, Cognitive Responses and Attitude Change

The present study focuses on the effects of graphic warnings related to excessive gambling. It is based upon a theoretical model derived from both the Protection Motivation Theory (PMT) and the Elaboration Likelihood Model (ELM). We focus on video lottery terminal (VLT), one of the most hazardous format in the gaming industry. Our cohort consisted of 103 actual gamblers who reported previous gambling activity on VLT's on a regular basis. We assess the effectiveness of graphic warnings vs. text-only warnings and the effectiveness of two major arguments (i.e., family vs. financial disruption). A 2 × 2 factorial design was used to test the direct and combined effects of two variables (i.e., warning content and presence vs. absence of a graphic). It was found that the presence of a graphic enhances both cognitive appraisal and fear, and has positive effects on the Depth of Information Processing. In addition, graphic content combined with family disruptions is more effective for changing attitudes and complying with the warning than other combinations of the manipulated variables. It is proposed that ELM and PMT complement each other to explain the effects of warnings. Theoretical and practical implications are discussed.

Perceived effectiveness of pictorial health warnings among Mexican youth and adults: a population-level intervention with potential to reduce tobacco-related inequities

Pictorial health warnings on cigarette packages are a prominent and effective means of communicating the risks of smoking; however, there is little research on effective types of message content and socio-demographic effects. This study tested message themes and content of pictorial warnings in Mexico. Face-to-face surveys were conducted with 544 adult smokers and 528 youth in Mexico City. Participants were randomized to view 5-7 warnings for two of 15 different health effects. Warnings for each health effect included a text-only warning and pictorial warnings with various themes: "graphic" health effects, "lived experience", symbolic images, and testimonials. Pictorial health warnings were rated as more effective than text-only warnings. Pictorial warnings featuring "graphic" depictions of disease were significantly more effective than symbolic images or experiences of human suffering. Adding testimonial information to warnings increased perceived effectiveness. Adults who were female, older, had lower education, and intended to quit smoking rated warnings as more effective, although the magnitude of these differences was modest. Few interactions were observed between socio-demographics and message theme. Graphic depictions of disease were perceived by youth and adults as the most effective warning theme. Perceptions of warnings were generally similar across socio-demographic groups.

Effectiveness of the European Union text-only cigarette health warnings: findings from four countries

The European Commission requires tobacco products sold in the European Union to display standardized text health warnings. This article examines the effectiveness of the text health warnings among daily cigarette smokers in four Member States. Data were drawn from nationally representative samples of smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006). We examined: (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact; and (iii) differences on the LII by demographic characteristics and smoking behaviour. Scores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Across all countries, scores were significantly higher among low-income smokers, smokers who had made a quit attempt in the past year and smokers who smoked fewer cigarettes per day. The impact of the health warnings varies greatly across countries. Impact tended to be highest in countries with more comprehensive tobacco control programmes. Because the impact of the warnings was highest among smokers with the lowest socioeconomic status (SES), this research suggests that health warnings could be more effective among smokers from lower SES groups. Differences in warning label impact by SES should be further investigated.

Impact of the New Malaysian Cigarette Pack Warnings on Smokers’ Awareness of Health Risks and Interest in Quitting Smoking

The objective of this research was to compare the response of adult smokers in Malaysia to newly proposed pictorial cigarette warnings against the current text-only warnings. The study population included 140 adult male smokers who were enrolled in a randomized trial to view either the new pictorial warnings (intervention) or the old text-only warnings (control). Participants completed pre-exposure and post-exposure questionnaires that assessed their awareness of the health risks of smoking, response to the package warnings, and interest in quitting smoking. Exposure to the pictorial warnings resulted in increased awareness of the risks of smoking, stronger behavioral response to the warnings and increased interest in quitting smoking. The new warnings in Malaysia will increase smokers’ knowledge of the adverse health effects of smoking and have a positive effect on interest in quitting.

Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study

ObjectiveTo assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries.Method1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese...

Adolescents’ Perceptions of Tobacco Control Measures in the United Kingdom

Understanding youth perceptions of measures that either encourage or discourage youth smoking is critical to help inform and consolidate tobacco control policy. Twelve focus groups, comprising adolescent smokers (N = 32) and nonsmokers (N = 35) aged 11 to 16 years were conducted in Glasgow and Lothian, Scotland. Each focus group explored factors adolescents encounter in everyday life that they perceive to facilitate or impede smoking, and about smoke-free legislation, smoking in domestic situations, access to cigarettes, and health warnings. It emerged that antitobacco advertisements and smoke-free legislation were considered of value in terms of being capable of reducing smoking. Although some adolescent smokers believed that adult smokers would not stop smoking because of a smoking ban, but instead compensate by smoking more elsewhere, such as at home, most adolescents with smoking parents or relatives indicate that this has not happened. Tightening regulation on ease of access to cigarettes was considered a suitable means of reducing youth smoking, although some smokers suggested that this could be easily circumvented by having others purchase tobacco on their behalf. Despite high awareness, text-only health warnings were not considered to discourage smoking. Point-of-sale tobacco displays however were considered to encourage smoking--being cool, fun, and attractive.

Adolescents' response to text-only tobacco health warnings: results from the 2008 UK Youth Tobacco Policy Survey

As of June 2009 most (89%) European Union member states continue to use mandated text-only health warnings on tobacco products. This study assessed adolescent (aged 11-16 years) perceptions of and reactions to these text warnings on cigarette packs in the UK. Data comes from wave five of the cross-sectional Youth Tobacco Policy Survey in 2008. A total of 1401 adolescents were recruited and health warnings were assessed in terms of salience (noticing, reading), comprehension and credibility, memorability (recall), depth of processing (contemplating, discussing) and persuasiveness (put off smoking, make more likely to stop). Smokers were also asked about behavioural compliance (foregoing cigarettes due to warnings, avoidance of warnings) and perceptions of harm from their smoking (to indirectly assess possible knowledge gained from warnings). Despite moderately high salience of warnings, memorability and, in particular, depth of processing was quite low, with warnings only sometimes thought about and very rarely discussed. Warnings were however considered comprehensible, credible and a reasonable deterrent for occasional and never smokers. Additionally, a third of regular smokers indicated that, in the last month, warnings had stopped them from having a cigarette. However, only 6% of smokers indicated that warnings made them forego cigarettes frequently. Text warnings help to communicate the dangers associated with smoking and, resultantly, prompt a small number of smokers to forgo cigarettes and take action to avoid warnings, but depth of processing is low and warnings do not appear to be achieving their full potential among smokers.

Gruesome photos on cigarette packages reduce tobacco use

Gruesome photos on cigarette packages reduce tobacco use

Impact of graphic and text warnings on cigarette packs: findings from four countries over five years

Objectives:To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii)...

Estimating the impact of different cigarette package warning label policies: The auction method

The study estimated the reduction in demand associated with implementing cigarette package warning labels that contain imagery illustrating the consequences of smoking. The experimental auction method was used, wherein adult smokers in Mexico ( n = 89) placed separate bids on two packs of cigarettes: one with a text-only warning label and the other with a warning label that included text and a graphic image. Differences in the values attributed to each pack were assessed using t-tests and multivariate regression. The pack with the graphic image had a mean attributed value which was 17% lower ($3.21 pesos) than the pack with the text-only warning, and this difference remained statistically significant within subgroups defined by sociodemographics, amount of smoking, number of quit attempts, and levels of perceived smoking risks. In the multivariate model, the difference in attributed values was greater among females than males, but no such differences were found for other sociodemographic or smoking-related variables. The consistently lower value that smokers attributed to cigarette packages with the graphic warning label indicates that these labels are likely to reduce cigarette demand.

Can Cigarette Warnings Counterbalance Effects of Smoking Scenes in Movies?

Scenes in movies where smoking occurs have been empirically shown to influence teenagers to smoke cigarettes. The capacity of a Canadian warning label on cigarette packages to decrease the effects of smoking scenes in popular movies has been investigated. A 2 x 3 factorial design was used to test the effects of the same movie scene with or without electronic manipulation of all elements related to smoking, and cigarette pack warnings, i.e., no warning, text-only warning, and text+picture warning. Smoking-related stereotypes and intent to smoke of teenagers were measured. It was found that, in the absence of warning, and in the presence of smoking scenes, teenagers showed positive smoking-related stereotypes. However, these effects were not observed if the teenagers were first exposed to a picture and text warning. Also, smoking-related stereotypes mediated the relationship of the combined presentation of a text and picture warning and a smoking scene on teenagers' intent to smoke. Effectiveness of Canadian warning labels to prevent or to decrease cigarette smoking among teenagers is discussed, and areas of research are proposed.

Posted Warnings, Compliance, and Behavioral Intent

The purpose of this study was to examine behavioral compliance with posted warnings varying in design features. Thirty-seven participants performed a chemical mixing task in an environment with no posted warning, a text-only warning, or a warning consisting of design components identified in the warnings literature (i.e., signal word, alert symbol, color). Participants were randomly assigned to one of three direct experience sign conditions. Participants also provided ratings of behavioral intent in conditions involving written scenarios and photographs of the task setting. Although eleven of the participants wore either gloves or goggles or both, none of the participants in the sign conditions looked at the posted warning signs. Ratings of behavioral intent in response to written scenarios revealed significant effects of sign type, and significant differences between ratings of self and ratings of others. Factors relating to research design and sample selection as well as implications for future compliance research are discussed.