Pictorial Health Warnings on Cigarette Packs in the United States: An Experimental Evaluation of the Proposed FDA Warnings (original) (raw)
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Nicotine & Tobacco Research, 2013
introduction: In 2011, the Food and Drug Administration published a final rule requiring cigarette packages and advertisements to include graphic health warning labels (HWLs) with new warning statements. Implementation of this rule has been stalled by legal challenge. This study assessed correlates of smoking-related intentions related to graphic HWLs among current cigarette smokers and nonsmokers in a national sample of U.S. young adults aged 18-34. Methods: Data were collected from 4,236 participants aged 18-34 using an online panel in January 2012 for the Legacy Young Adult Cohort Study. Analyses were weighted to provide nationally representative estimates. Our main outcome was assessed with a single item: "Do you think that new warning labels with graphic pictures would make you think about not smoking?" results: Twenty-two percent of the young adults were current cigarette smokers. Fifty-three percent endorsed that new graphic HWLs would make them think about not smoking (40% among current smokers compared with 56% among nonsmokers). Among nonsmokers, those aged 18-24, females, Hispanics, and those who were aware of graphic cigarette HWLs were more likely to report intention to not smoke related to graphic HWLs. Among current smokers, intending to quit within the next 6 months was correlated with intention resulting from graphic HWLs. Hispanic ethnicity and intention to quit within 30 days were strong correlates of intention in light, nondaily, and self-identified social/occasional smokers. Conclusions: This study supports previous findings that graphic HWLs play an important role in preventing smoking, in addition to encouraging cessation in young adults. intrOdUCtiOn In 2010, the Food and Drug Administration's Center for Tobacco Products (FDA CTP) proposed regulation requiring large, graphic health warning labels (HWLs) and nine new warning statements, as dictated by the Family Smoking Prevention and Tobacco Control Act, to be included on cigarette packages and in cigarette advertisements. Although published as a final rule in 2011, implementation has been stalled by two lawsuits brought by tobacco companies (Food and Drug Administration, 2012) and a U.S. Court of Appeals decision in one of the cases that the graphic warnings proposed violated First Amendment speech protections (R.J. Reynolds Tobacco Co. v. Food and Drug Admin, 2012). In the August 2012 decision, the court affirmed that the FDA did not provide the evidence needed to support that the graphic HWLs would "directly advance" its interest in reducing the number of Americans who smoke (R.J. Reynolds Tobacco Co. v. Food and Drug Admin, 2012). In March 2013, the government affirmed that it would not appeal the case and that the FDA would "undertake research to support a new rulemaking consistent with the Tobacco Control Act" (Associated Press, 2013). Longitudinal data from countries with established graphic HWLs (Australia and Canada) suggest that HWLs reduce smoking prevalence, increase quit attempts, and reduce relapse among ex-smokers (Azagba & Sharaf, 2013; Partos, Borland, Yong, Thrasher, & Hammond, 2013). Both youth and adults are more likely to recall larger warnings, rate larger warnings as having greater impact, and equate the size of the warning with the magnitude of the risk (
Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior
JAMA Internal Medicine, 2016
IMPORTANCE Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. OBJECTIVE To assess the effect of adding pictorial warnings to the front and back of cigarette packs. DESIGN, SETTING, AND PARTICIPANTS 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. INTERVENTIONS 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). MAIN OUTCOMES AND MEASURES 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. RESULTS 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. CONCLUSIONS AND RELEVANCE 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. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02247908
Reactions of Young Adult Smokers to Warning Labels on Cigarette Packages
American Journal of Preventive Medicine, 2006
Background: In 1984, the United States Congress enacted legislation requiring four new warning labels for cigarettes; warning labels in the United States have not changed since then. Other countries, such as Canada, have taken a more active and aggressive approach. The purpose of this study was to examine how U.S. smokers and former smokers might respond to stronger and more graphic warnings for U.S. cigarettes packages.
Journal of Public Policy & Marketing - J PUBLIC POLICY MARKETING, 2006
The World Health Organization recently adopted the Framework Convention on Tobacco Control, a groundbreaking public health treaty that will require that warning information in the form of text, pictures, or a combination of these two forms cover at least 30% of the front and back of cigarette packages. In three studies using smokers from the United States and Canada, the authors examine the effects of specific graphic visuals in the context of current U.S. verbal warnings. The findings indicate that including both graphic visual warnings, such as those used in Canada, and warning statements currently used in the United States can decrease the perceived attractiveness of the package and create higher levels of negative affect, such as fear or anxiety. The results also show that the addition of the specific visual warnings examined to the U.S. statements increases smokers' perceived intentions of quitting smoking compared with warning statements alone. The authors offer implications for public policy and public health and provide suggestions for further research.
Systematic Review of the Effect of Pictorial Warnings on Cigarette Packages in Smoking Behavior
American Journal of Public Health, 2014
c 2 = appropriate PWCP; 1 = appropriate pictorial warning intended for printing in cigarette packages or inappropriate PWCP (e.g., very short exposure duration or lack of an unexposed control group); 0 = inappropriate warning (not a PWCP or intended for printing in cigarette packages). d 2 = pertinent and adjusted; 1 = not pertinent or unadjusted; 0 = not pertinent and unadjusted. e 0-2 = very poor; 3-4 = poor; 5-6 = fair; 7-8 = good. f These articles used similar or identical data for analyses. g
Pictorial cigarette pack warnings: a meta-analysis of experimental studies
Pictorial cigarette pack warnings: a meta-analysis of experimental studies, 2016
Objective To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. Data sources We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. Study selection We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Data extraction and synthesis Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Results Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. Conclusions The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
Systematic Reviews
Background: Graphic health warnings on tobacco packaging and the plain packaging of tobacco products are key tobacco control interventions. This systematic review investigates the perceptions of adolescents towards these packaging interventions. Methods: Published, original-research, English-language articles from 1 January 2000 to 1 September 2017 were identified through a systematic literature search of the PubMed, CINAHL, PsycINFO, Web of Science, and Scopus databases. Articles describing investigations into the perceptions of adolescents aged 11 to 19 years towards graphic health warnings and/or plain-packaged cigarettes were included in this review. Results: Nineteen articles, involving 15,935 adolescent participants, of which 72.85% were non-smokers or exsmokers and 27.15% occasional or daily smokers, met the eligibility criteria. Graphic health warnings were perceived as more effective than text-only warnings, with warnings depicting lung cancer, and oral diseases being perceived as particularly effective. Health warnings increased viewer fear, anxiety, shock, and guilt and were considered effective in preventing non-smokers from experimenting with tobacco and prompting current smokers to quit. Plain packaging reduced the attractiveness and other positive attributes of cigarette packaging, with darker colours found to be the most effective. When used in combination, plain packaging increased the visibility of graphic health warnings, with participants also perceiving them as having an increased tar content and having more serious health risks, and increased thoughts of quitting amongst smokers. Conclusions: Graphic health warnings and plain packaging appear to increase adolescent awareness of the dangers of tobacco use. Further research into the most effective warnings to use in combination with plain packaging is needed to ensure the greatest reduction in tobacco use and prevent tobacco-attributable morbidity and mortality in this vulnerable population.
Pictorial Health Warning Labels on Cigarette Packages: An Investigation on Opinions of Male Smokers
Iranian Red Crescent Medical Journal, 2014
Background: Health warning labels on cigarette packages are among the most straightforward and important tools to communicate with smokers and various studies have illustrated their efficacy. Objectives: The current study aimed to investigate the opinions of male smokers in Mashhad city about the efficacy of health warning labels printed on cigarette packages on the smoking status of smokers. Patients and Methods: This cross-sectional descriptive study was conducted in 2013 using a questionnaire. The research population included the male smokers of Mashhad. The participants were selected from the customers referring to the newsstands for cigarettes. The obtained data were analyzed employing SPSS software Version 16, and the statistical tests including Kruskal-Wallis, Spearman, and correlation coefficient of Pearson, Chi Square, Mann-Whitney, and Bonferroni correction were used in this regard. Results: In this research, there were 500 participants with the average age of 25 years. The initiation age of smoking was eight years while the maximum age was reported as 45 years. Results of this research about the effect of these labels on decreasing cigarette consumption rate showed that almost half of the participants believed that these labels were ineffective for them (52.2%) and other smokers (53.8%). Furthermore, significant relationship was found between the age and opinion of the smokers about the influence of these labels on reducing their cigarette consumption (P < 0.001). Conclusions: To promote the effect of printed images on cigarette packages, it is recommended to consider the suitability of labels in the targeted culture. In addition, to be more effective consultation sites to quit smoking should be introduced under the images.