Graphic warnings help reduce

smoking – US study
BY BEN KRITZ, TMT
AUGUST 29, 2016

GRAPHIC warnings printed on cigarette packs about the dangerous

effects of smoking have encouraged more smokers to reduce
smoking or quit the habit altogether than text-only warnings, a new
study by researchers at the University of North Carolina has found.

The study, entitled “The impact of strengthening cigarette pack

warnings: Systematic review of longitudinal observational studies,”
was carried out by a team of researchers from the University of
North Carolina Lineberger Comprehensive Cancer Center. The
team was led by Dr. Seth Noar, who is also a professor at the UNC
School of Media and Journalism. The National Cancer Institute and
FDA Center for Tobacco Products funded the study, and it was
published in this month’s edition of the journal Social Science &
Medicine.

The study gathered and assessed the results of 32 earlier research

studies conducted in 20 countries. Twenty of the studies specifically
analyzed the impact of replacing text warnings on the cigarette pack
with graphic warnings that include text and pictures, while the
remaining studies looked at efforts to strengthen existing text or
picture warnings in other ways, such as changing their size, content,
or position on the pack.

The Philippines was not among the 20 countries studied in the

earlier research, despite an aggressive campaign by the government
through the Department of Health to enforce the use of graphic
warnings on cigarette packs.

“Our review focused on studies that analyzed smoking behavior and

other outcomes conducted in the real world where countries had
implemented new warning policies,” Noar said. He explained that
in his team’s study, the US was used as a control, as text-only
warnings on cigarettes persist in spite of a 2011 rule by the US
Food and Drug Administration requiring graphic warnings.
However, the FDA rule was blocked by the US Court of Appeals in
response to a legal challenge by tobacco companies. The case is not
yet resolved.

Promising results
In the study’s introduction, the researchers highlighted that their
work was the first study to pool data from thousands of participants
across multiple studies and estimate the size of population-wide
effects of strengthening cigarette pack warnings. This allowed them
to draw general conclusions from the research results.

Among the specific findings, the study found that strengthening

warnings led to a 10 percent relative increase in knowledge about
the health effects of smoking among smokers, which increased to
32 percent when countries added new warning content. Graphic
warnings or otherwise strengthened warnings also resulted in a 9
percent relative increase in quit attempts, and a 13 percent relative
reduction in smoking prevalence.

The research also found that calls to “quit smoking” telephone help
lines increased in four out of six studies, overall cigarette
consumption measured on national scales decreased in three of
eight studies, and reported attempts to quit increased in four out of
seven studies.

The researchers noted that when the studies that addressed health
warning efforts other than graphic warnings were excluded, the
results of their overall analysis was identical, leading them to
conclude that graphic warnings are indeed effective in encouraging
smokers to quit.
The researchers were careful to note that because the study gathered
real-world results, other factors could have contributed to the
declines in smoking behavior observed in the review. For example,
Noar explained, countries that strengthened their warnings
sometimes made other changes, such as implementing media
campaigns, raising taxes on cigarettes or implementing advertising
restrictions.

Nevertheless, he highlighted an independent commentary on his

team’s research, a review by professor Joseph Cappella of the
University of Pennsylvania and published along with the research
study, which stated, “Putting this review in the context of other
recent controlled studies about cigarette warnings, we see an
emerging picture of the causal effectiveness of warning labels
emerges that is difficult to ignore.”

In a follow-up statement Noar said, “One of the responsibilities of

governments is to educate the populace about the many negative
health effects of smoking. Our review clearly demonstrates that
stronger warnings—particularly graphic warnings—achieve this in
a more effective way than text-only warnings. When combining this
review with other research evidence that’s continuing to emerge, we
see that warnings clearly have a real-world impact on knowledge,
attitudes, and, importantly, perhaps on behavior itself.”
How graphic photos on cigarette packs help smokers consider
quitting

COLUMBUS, Ohio – A new study is the first to provide real-world evidence of the
effectiveness of smoking warning labels that include graphic photos of the damage caused
by regular tobacco use.

Researchers found that smokers who saw graphic warning labels on every pack of
cigarettes they smoked for four weeks had more negative feelings about smoking
compared to those who saw just text warnings, which led them to look more closely
at the warnings and put more credence into them. This was associated with them
thinking their habit was more dangerous and being more likely to consider quitting.
They also remembered more of the health risks of their habit.

Ellen Peters

“The graphic images motivated smokers to think more deeply about their habit and
the risks associated with smoking,” said Ellen Peters, co-author of the study and
professor of psychology at The Ohio State University.

Abigail Evans

The study, which was a joint project between Ohio State and the Annenberg Public
Policy Center of the University of Pennsylvania, appears in the journal PLOS ONE.
The research is the first to look at the impact of graphic warning labels on smokers
outside of a laboratory and over a relatively long period of time.
“Our study provides real-world evidence of how viewing these graphic images over
time has an impact on smokers beyond what occurs with simple text warnings,”
said Abigail Evans, lead author of the study and a postdoctoral researcher in
psychology at Ohio State.
Other co-authors were Daniel Romer of the University of Pennsylvania’s Annenberg
Public Policy Center; Andrew Strasser of the University of Pennsylvania; Lydia
Emery of Northwestern University; and Kaitlin Sheerin of the University of Missouri.
For the study, the researchers used graphic warning labels created by the U.S. Food
and Drug Administration. One of the labels included an image of a man smoking
through a hole in his throat, called a tracheostomy. A tracheostomy may be
necessary as a result of some smoking-related cancers.
The use of graphic warning labels was mandated by law to appear on cigarette
packs in the United States in 2009. The warnings proposed by FDA were later
invalidated by a federal appeals court. The court concluded the labels were
unconstitutional in part because the images were “unabashed attempts to evoke
emotion … and browbeat consumers into quitting.”
This study suggests that the court was not correct in its assessment of how these
images work to discourage smoking, Peters said.
“Smokers weren’t browbeaten by the images. The images definitely did stir their
emotions, but those emotions led them to think more carefully about the risks of
smoking and how those risks affected them,” Peters said.
“What the court is missing is that without emotions, we can’t make decisions. We
require having feelings about information we collect in order to feel motivated to act.
These graphic warnings helped people to think more carefully about the risks and to
consider them more.”
The study involved 244 adults who smoked between 5 and 40 cigarettes each day.
Participants were provided with their preferred brand of cigarettes for four weeks, in
modified packages. All packages had the same text messages, such as “Cigarettes
cause fatal lung disease.” Some participants received packs with only these
messages. Some received packs with the text warnings plus one of nine graphic,
somewhat disturbing images showing the dangers of smoking. A third group
received the simple text and the image, plus additional text detailing how every
cigarette entails risk.
Participants returned to the lab each week to receive additional cigarettes and
respond to surveys about their experiences with the new packaging.
Results showed that smokers who had the warning labels with the graphic labels
were more likely than those who received only text warnings to report that the
packaging made them feel worse about smoking. They were also more likely to read
or look closely at the information on the warning labels and they better remembered
what was on the labels.
Smokers who had the graphic labels also saw the warnings as more credible.
“The feelings produced by the graphic images acted as a spotlight. Smokers looked
more carefully at the packages and, as a result, the health risks fell into the spotlight
and led to more consideration of those risks,” Peters said.
Smokers who viewed the graphic labels were also slightly more likely to say they
intended to quit smoking.
“For a health issue like smoking, which causes about a half-million deaths a year in
the United States, even small effects can have a large impact in the population,”
Peters said.
“The effect was small, but it was not unimportant.”
The results show warning labels with graphic images really do work, Evans said.
“Policies requiring such labels have the potential to reduce the number of Americans
who smoke,” she said.
The study was supported by grants from the National Cancer Institute and the FDA
Center for Tobacco Products.
The Impacts of Cigarette Packaging Pictorial Warning Labels
on Smokers in the City of Tehran
Gholam Reza Heydari,1 Ali Ramezankhani, 2
and Firoozeh Talischi1

Author information Article notes Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
Go to:

INTRODUCTION
Cigarette smoking is the most important preventable cause of early deaths, morbidity and
mortality in the world (1). Social, familial, and personal factors play an important role in
prevention or cessation of smoking (2). Every 6 seconds, 1 person dies as the result of
tobacco consumption in the world (3). Smoking results in the death of half the smokers (4)
and shortens their life spam for an average of 15 years (5, 6). If necessary actions are not
taken to overcome this obstacle, the annual rate of morbidity and mortality due to tobacco
consumption will reach to more than 8 million people by the year 2030 (7). If the current
pattern of smoking continues, it is estimated that 500 million would die as the result of
tobacco consumption (7). During the 21st century, consumption of tobacco products will
result in the death of more than one billion people (8).
Although there is definitive evidence regarding the health hazards of tobacco consumption,
only a small number of smokers are fully aware of the harmful effects of this act. People
generally know that smoking is dangerous. However, they think of it as a bad habit that they
are knowingly involved with (9). Adopting pictorial health warning labels on cigarette packs
improves smokers’ knowledge about the health hazards of smoking (10). The effect of
pictures showing disease complications is much greater than the text only warnings. Pictorial
health warnings are particularly required to target the illiterate population of the world.
Studies in Australia (11), Belgium, Brazil (12), Canada (13), Thailand, and some other
countries show that health warnings on cigarette packs especially the graphic ones are an
important source of information for young smokers in low education countries. These
pictorial warnings especially target the children of smoker parents who are at a greater risk
for becoming a smoker themselves. Some countries do not apply any health warning labels to
cigarette packs. At present, it is emphasized that the warning labels should be large, bold,
very clear and preferably graphic and should at least occupy half the packet and indicate the
health hazards of smoking and related diseases. The warning messages should be written in
official language of the country in a way that it is easily understandable for the public.
Evaluation of the public opinion shows that tobacco free laws and regulations have been
greatly appreciated in every country they have been implemented in (14). Iran is a member of
the WHO Framework Convention on Tobacco Control. According to the Article 5 of the
executive protocol compiled by the National Comprehensive Law on Tobacco Control,
pictorial health warning labels should be applied to cigarette packs.
We designed this study to evaluate the effect of cigarette packs’ pictorial health warning
labels on the knowledge, attitude and pattern of smoking in smokers residing in Tehran.
Go to:
MATERIALS AND METHODS
This was a cross sectional descriptive study conducted to evaluate the effect of cigarette
packs’ pictorial warning labels on the knowledge, attitude and smoking pattern of smokers
residing in Tehran. Data were collected in 2 phases: fall 2008 and summer 2009. At the time
of study, participants had at least one year history of smoking and were residing in one of the
22 districts of Tehran. A questionnaire was used for data collection. With the cooperation of
the Statistics Center of Iran, using the Tehran map and evaluating the population residing in
each district using the PPS method, the required number of subjects from each district was
determined. A location was selected in each chosen district randomly and questioning was
started from there moving upwards and to the right. Our questionnaire was a self study
questionnaire designed according the standard questionnaire of the WHO and IUATLD. Its
efficacy and reliability were tested on the first phase of study. Data regarding pattern of
smoking, knowledge about the implementation of pictorial warning labels on cigarette packs
and smokers’ attitude towards it were collected in 2 phases and evaluated using SPSS version
11 software. Relative distribution and frequency of the variables were calculated. Chi square,
Wilcoxon, McNemar and spearman's rank correlation coefficient tests were used for
comparison between variables and P < 0.05 was considered significant (Figure 1).
Open in a separate window
Open in a separate window
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Figure 1

Pictorial warning labels

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RESULTS
The results of the first phase demonstrated that 1,731 smokers were questioned out of which,
71.8% were males and 28.2% were females. The mean age was 36.6±13.6 yrs (range 17 to 60
yrs). A total of 41.4% had high school diploma. The mean history of smoking was 17.6±12.3
yrs (range 2 to 44 yrs). A total of 39.2% had their first cigarette within 30 min after waking
up and 657 cases (38%) used Iranian cigarette brands. In the first phase, 39.5% were aware of
the implementation of pictorial warning labels on cigarette packs, 41.2% had no opinion in
this regard and 576 cases (33.3%) predicted that this act may result in decreasing their
smoking rate (Table 1).

Table 1
Demographic characteristics of understudy smokers in Tehran before and after the
implementation of protocol.
 Before After

Gender No. (%) No. (%)

Male 1242 (71.8) 1145 (72)

Female 489 (28.2) 445 (28)

Knowledge

Yes 684 (39.5) 1519 (95.5)

No 1047 (60.5) 71 (4.5)

Attitude

Very positive 360 (20.8) 329 (20.7)

Positive 501 (28.9) 453 (28.5)

No opinion 714 (41.3) 598 (37.6)

 Before After

Negative 156 (9.0) 210 (13.2)

Cigarette consumption Prediction of consumption Consumption

No. (%) No. (%)

More 396 (22.9) 191 (12)

Same 759 (43.8) 1278 (80.4)

Less 576 (33.3) 121 (7.6)

All respondents 1731 (100.0) 1590 (100.0)

Open in a separate window

A total of 39.17% (615 males and 63 females) lit their first cigarette within 30 minutes after
waking up in the morning. Males and females showed a statistically significant difference in
this respect (P < 0.001). Thirty eight percent of the participants used an Iranian brand (47.8%
of men and 12.9% of women). Difference in this respect was significant between males and
females (P < 0.001). A total of 39.5% of the smokers were aware of this new rule. Women
had a significantly greater knowledge in this respect (P < 0.001). No significant correlation
was observed between the knowledge about this new rule and occupation or educational level
of participants. Age and knowledge or attitude had no significant correlation either.
In the second phase of the study 1,590 participants were questioned for the 2nd time(Table 2).
Although Wilcoxon signed-rank test showed no significant decrease in rate of smoking (P =
0.86, difference in means: -0.179), 121 persons (7.6%) cut down on smoking compared to
their previous consumption rate in phase 1 of the study out of which 88.42% were males.
Difference in this regard was statistically significant (P < 0.001). No correlation was found
between decreased rate of smoking and cigarette brand in terms of domestic or foreign brands
(P = 0.10). However, a significant correlation was observed between smoking in the first 30
min after waking up and decreased rate of smoking.

Table 2
Frequency distribution of cigarette consumption after implementing the pictorial warning
labels on cigarette packs based on gender in the 2nd phase of study.

Gender Frequency of cigarette consumption Total

Higher No change Lower

Male No. (%) 86 (7.5) 952 (83.1) 107 (9.3) 1145 (100)

Female No. (%) 105 (23.6) 326 (73.3) 14 (3.1) 445 (100)

Total No. (%) 191 (12) 1278 (80.4) 121 (7.6) 1590 (100)

In a paired study on 1,590 cases before and after the implementation of pictorial warning
labels on cigarette packs the following results were obtained:
Knowledge about this new law increased significant using the Mcnemar's test (P < 0.001)
(Tables 3, ,44).
Table 3
Frequency distribution of cigarette consumption after implementing the pictorial warning
labels on cigarette packs based on age in the 2nd phase of study.

Age Frequency of cigarette consumption Total

Higher No change Lower

Younger than 30 yrs No. (%) 48 (6.9) 592 (84.9) 57 (8.2) 697 (100)

30-50 yrs No. (%) 88 (16.7) 420 (79.7) 19 (3.6) 527 (100)

Older than 50 yrs No. (%) 55 (15) 266 (72.7) 45 (12.3) 366 (100)

Total No. (%) 191 (12) 1278 (80.4) 121 (7.6) 1590 (100)

Table 4
Frequency distribution of cigarette consumption after implementing the pictorial warning
labels on cigarette packs based on the time of first cigarette smoking in the morning in the
2nd phase of study
Time of first cigarette in the morning Frequency of cigarette consumption Total

Higher No change Lower

In 30 min after waking up No. (%) 39 (12.5) 270 (86.3) 4 (1.3) 313 (100)

In 31-60 min No. (%) 121 (18.5) 529 (80.9) 4 (0.6) 654 (100)

After 60 min No. (%) 31 (5) 479 (76.9) 113 (18.1) 623 (100)

Total No. (%) 191 (12) 1278 (80.4) 121 (7.6) 1590 (100)

Attitude towards the positive effect of this law did not change significantly using the
Wilcoxon signed-rank test (P = 0.641, difference in means:-0.005). Picture number 4 was
selected as the most influential picture among the total 6 which was a picture from a smoker
suffering from Buerger's disease (Table 5).

Table 5
Frequency of the most influential picture chosen by the respondents.
Picture number No. (%)

Picture # 1 193 (12.1)

Picture # 2 178 (11.2)

Picture # 3 369 (23.2)

Picture # 4 690 (43.4)

Picture # 5 133 (8.4)

Picture # 6 27 (1.7)

Picture # 7 1590 (100)

Go to:

DISCUSSION
Applying pictorial warning labels to cigarette packs is the only definitive way to expose
smokers to such warnings. Cigarette manufacturers have always taken advantage of attractive
cigarette packaging to propagate their product in the market. Warning labels reverse the
efficacy of their marketing.
Implementation of warning labels on cigarette packaging enhances the knowledge of
consumers about the harmful effects of tobacco products (10). The effect of pictures of
smoking related diseases is much greater than text only warnings. These pictorial warnings
are necessary for the huge number of illiterate population of the world in order to inform
them about the health hazards of smoking. Studies in Australia (11), Belgium, Brazil (12),
Canada (13), Thailand, and some other countries show that health warnings on cigarette
packs especially the graphic ones are an important source of information for young smokers
in low education countries. These pictorial warnings especially target the children of smoker
parents who are at a greater risk for becoming a smoker themselves. Graphic warnings are
usually supported and approved by the public and there is rarely an objection towards them.
However, cigarette manufacturers oppose this act. Health warnings encourage smokers to
quit smoking and can prevent initiation of smoking in the younger population. It also
increases public acceptance towards other tobacco control strategies such as creating smoking
free zones. This study was conducted in 2 phases (fall 2008 before applying pictorial warning
labels and after their implementation in summer 2009) and evaluated the effect of adopting
pictorial warning labels as one of the tobacco control programs.
In the first phase, less than 40% of the smokers were aware of the implementation of this law
which seems like an unacceptable number. This rate reached 95% in the second phase. There
is a possibility that smokers who were not aware of this law where those who used cigarettes
with no pictorial labels. Authorities should especially pay attention to this subject and make
sure all the cigarette packs available in the market adopt these pictorial warning labels.
In the first phase, almost half the participants had no opinion regarding this action and were
unsure about the effects of its implementation. This rate did not change in the second phase
of the study. Special attention should be paid to this issue to figure out why this action had no
effect on changing the attitude of smokers. Poor quality of the pictures or not so effective
messages may play a role in this respect. An important finding was changed rate of smoking
in the 2nd phase of study as follows: 33% of smokers in the first phase predicted that
implementation of pictorial warning labels would decrease their smoking rate. This figure in
the second phase reduced to 7.7%. Although, a small number of smokers actually cut down
on smoking or started thinking about quitting as the result of implementation of this act, this
rate is acceptable and almost similar compared to other studies’ findings (10–12). According
to international studies, implementation of this act is beneficial even at such low rates.
However, we have to work on finding solutions to increase this rate. This goal can be
achieved by improving the quality of pictorial health warnings, selecting influential pictures,
seeking public opinion, and applying pictorial warning labels to the packaging of all cigarette
brands.
Our study results demonstrated that smoking rate decreased in men more than women. Also,
smoking rate decreased mostly in those who did not smoke in the first 30 minutes after
waking up (low nicotine dependence)(18.1% versus 1.3%). Older smokers were more
affected by the implementation of this act (12.3% versus 3.6%). Such findings have not been
reported in other studies (11, 12). To our knowledge, our study was the first to report such
findings.
Another important factor to discuss is the fact that the picture showing a healthy and a
diseased lung caught the lowest and the picture depicting laryngeal cancer and Buerger's
disease caught the highest attention among smokers. This finding can help in selecting future
pictures.
In future, studies designing pictures based on ethical and cultural backgrounds should be
evaluated.
This study was conducted in 2 phases before and after the implementation of pictorial health
warnings. This way we could evaluate the effect of this law. Our study results demonstrated
that these pictorial warnings did not have any effect on changing the attitude of smokers on
cutting down or quitting smoking. Also, smokers’ prediction about decreasing the rate of
smoking after the implementation of this act did not come true and decreased consumption
occurred in only 7% of cases. However, this rate is acceptable and almost similar to those
reported by foreign studies. More influential pictures are required in order to achieve the
goals set for tobacco control.
Go to:

CONCLUSION

Phase 1
 Consumption of foreign cigarette brands was more than 60%
 About 60% of the smokers were not aware of this act
 Nicotine dependence was greater in men
 Consumption of foreign brands was higher among women
 Nicotine dependence was greater in smokers older than 50 years old
 Consumption of Iranian cigarette brands was higher among those over 50 years old
 Knowledge about this law was greater among women
 Almost half the smokers did not have a positive attitude towards this law and did not
think it would be effective
 33% of smokers did not think that they would cut down on smoking after the
implementation of these warning labels

Phase 2
 Knowledge about the law enhanced significantly
 Still more than half the smokers did not have a positive attitude towards this law and
did not think that it would be effective
 About 7% of smokers stated that they had cut down on smoking. This decrease in
smoking rate was greater in males (almost 3 times higher), older ages (almost 4 times
greater), and those with low nicotine dependence (almost 10 times greater)
 About 10% of smokers believed that the quality of the attached picture was good. No
significant difference was detected in this respect based on age, sex or nicotine
dependence.
 Smokers chose the picture of Buerger's disease and laryngeal cancer as the most
influential graphic pictures. No significant difference was observed in this regard
according to age, sex or nicotine dependence

Final conclusion
 Foreign cigarette brands are more popular than domestic brands and are mostly
consumed by women and people of younger ages
  Knowledge about the implementation of pictorial health warnings on cigarette packs
has significantly enhanced
 Attitude towards the positive effect of this act has remained unchanged
 Prediction of decrease in smoking rate following the implementation of this act did
not come true
 Smokers believe that picture of a laryngeal cancer and Buerger's disease is the most
influential ones.
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Acknowledgement
This study was supported by the Tobacco Prevention and Control Research Center, NRITLD,
Shaheed Beheshti University of Medical Sciences. The authors would like to thank all those
who sincerely cooperated in the conduction of this study.
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Implications of Graphic Cigarette Warning Labels on
Smoking Behavior: An International Perspective
Minsoo Jung

Author information Article notes Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
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INTRODUCTION
Packaging is tobacco companies’ primary means of marketing due to the strengthening of
anti-smoking policy worldwide.1 Graphic warning labels (GWLs) have been developed as a
cost-effective policy for simultaneously inhibiting such marketing and conveying information
on the health risks incurred by smoking. The introduction of GWLs is effective for attracting
smokers’ attention and publicizing the harmfulness of tobacco.2,3 Article 11 of the
Framework Convention on Tobacco Control (FCTC) recommends the introduction of the
GWL for at least 50% of the packet cover and enforces countries directly involved to comply
within three years of adopting the Convention. In addition, the third general assembly of the
FCTC in 2008 recommended the introduction of plain packaging to prevent the advertising
effect through tobacco packs.4 Packing can have an effect of deluding consumers and
promoting the sales of tobacco. The present study systematically reviews the current state and
effect of the global introduction of GWLs and examines the future tasks related to GWLs.
Go to:

GRAPHIC WARNING LABELS AND RELATED DEBATES

The GWLs were first introduced to Canadian consumers in 2001. Subsequently, the FCTC
took effect in 2005 as an international effort to reduce deaths and illnesses due to tobacco,
and rapidly increased the number of countries adopting GWL. In particular, Canada
established the Tobacco Products Information Regulations in 2000 based on the Tobacco
Act.5 As a result, tobacco packaging with GWLs, anti-smoking warning messages, and
explanations on the emission and composition of toxic substances became mandatory.5 In the
early introduction of GWLs, the area on the package was extended to at least 30% of cigar,
pipe tobacco, hookah, and smokeless tobacco packaging and to at least 50% for ordinary
tobacco packs.5
GWLs swiftly spread worldwide. For example, the Thai government in 2004 passed a law
making it mandatory to attach GWLs on both the front and back sides, extending to 50% of
the entire cigarette packs.6 The sizes of the GWLs have expanded to no less than 85% of a
cigarette pack. The mandatory attachment of GWLs worldwide exceeds 82.5% in Australia
and 80% in Uruguay. Obviously, the tobacco industry has strongly opposed restrictions
through GWLs. The industry has argued that the harmfulness of tobacco is widely known
already, and that the attachment of GWLs to the packaging violates trademark rights and
copyrights and can incite the production of counterfeit tobacco.6 Such debates have led to
scientific discussions on whether the future introduction of GWLs will reduce smoking rates.
It is reported that tobacco packaging has a greater marketing effect than do other consumer
goods because the packaging is not discarded immediately after it has been opened.1,5 The
packing is exposed to those around the tobacco users a countless number of times until all of
the contents have been used up. In other words, adoption of GWLs is intended more to stop
tobacco companies’ from marketing than to provide health education to consumers by
publicizing the risks and harmfulness of smoking. In fact, tobacco companies have developed
tobacco packs with ‘cool’ or ‘feminine’ images to attract the attention of the young and
women and to strengthen their brand images through stealth marketing.5 Consequently, some
tobacco companies have lawsuits against the US Food and Drug Administration.7 This has
led to debates on the introduction of GWL effects.
In spite of the many debates, the effects of GWLs on smokers’ attitudes toward smoking
seem clear. The fear and anger generated when smokers are exposed to GWLs have a positive
effect on smoking cessation and a negative effect on smoking.8 According to a recent study
published in Tobacco Control, the strength of emotional responses generated after exposure
to GWLs determined the effect of GWLs.9 When functional magnetic resonance imaging of
neural responses generated after exposing smokers to GWLs were analyzed, the images
aroused strong emotional reactions, which increase cognitive efforts that accompany
information processing.10 This increases the memory of the images and reduces the desire to
smoke.9,10 In other words, smokers exposed to GWLs exhibited more fear and a stronger
intention to quit smoking than did smokers exposed to simple warning messages.
According to data announced by the Canadian Cancer Society in 2014, GWLs have been
introduced to seventy-six countries worldwide as of 2015. After all members of the European
Union adopt GWLs in 2016, GWLs will be implemented in at least ninety-four
countries.5 GWLs were adopted by only five countries in the early 2000s, twenty-nine
countries from 2006 to 2010, and forty-two countries from 2011 to 2015.5 GWLs are
scheduled to be adopted by eighteen countries in 2016. Thus, insertion of the GWLs on
tobacco packaging can be seen as a global trend.
Go to:

SCIENTIFIC EVIDENCE OF GRAPHIC WARNING LABELS

The introduction of GWLs may induce smokers to quit smoking, and thus lowers tobacco
consumption. In the case of Canada, smoking cessation motivation is reported to have
increased among half of the smokers since the adoption of GWLs.5,11 In Australia, GWLs
have aroused smoking cessation motivation among 60% of the smokers.12 Subsequently,
one-third of the smokers have attempted to quit smoking. Likewise, in Thailand, the intention
to quit smoking has increased among half of the smokers since the introduction of
GWLs.13 An increase in smokers’ smoking cessation efforts and actual smoking cessation
rates after the adoption of the GWL has affected tobacco consumption. In the case of
Singapore, 28% of smokers reported smoking fewer cigarette because of GLWs in 2004.14 In
addition, the adoption of GWLs has inhibited the number of new smokers and induced
current smokers to quit smoking.15 Importantly, a major cause in the reduction of tobacco
consumption lies in the inhibition by new smokers, including adolescents. According to
reports on the population conducted in Australia and Canada, the smoking prevention effects
of GWLs amount to a maximum of 60%.16,17 The introduction of GWLs more effectively
inhibits an increase in the number of smokers than do warning messages. This has been
confirmed for adolescents in European countries such as Greece.18
Second, the introduction of GWLs may decrease the overall smoking rates. In the case of
price policy, smoking rates drop according to an increase in tobacco prices.19 However,
tobacco consumption often returns to the normal consumption rate with the passage of time.
Yet, the adoption of GWLs exhibits a continuous smoking decrease effect in comparison with
price policy.20 In the case of Canada, the introduction of GWLs is estimated to have led to a
drop in the number of smokers by approximately 12% to 19%.19,20 Of course, predicting a
uniform decrease in smoking rates is difficult because the strength of graphic labels and the
presence of other warning messages differ by country. Nevertheless, according to research by
Huang et al.,19 smoking rates will decrease by a maximum of 5% if Canada’s GWLs are
applied to the United States. What is important is that the adoption of GWLs generally leads
to a continuous drop in smoking rates. In the case of Turkey, men’s smoking rate was
approximately 44% in 2008 and dropped to 39.0% in 2010 and 37.3% in 2012 due to the
introduction of GWLs.21
Third, the introduction of GWLs leads to additional effects such as the conveyance of health
information from the perspective of health communication. In Australia and Thailand, the
ability to convey information has been strengthened when warning messages were combined
with GWLs.12 In the case of China and Mexico, senior citizens, women, and low
socioeconomic status groups have been shown to recognize information more effectively on
diseases that are caused by smoking through GWLs.2,22 In addition, according to the results
of comparative studies among countries, tobacco consumers more accurately recognized
diseases due to cigarette smoke substances (3.4 times as much for carbon monoxide and 3.8
times as much for potassium cyanide) and smoking (2.7 times as much for impotence and 1.6
times as much for both strokes and cancer occurrence) with GWLs.23 The correct awareness
of health information has a potential effect of inducing smokers to voluntarily enhance the
use of smoking cessation services. In the case of the Netherlands, the number of calls to
smoking cessation hotlines has increased by 3.5 times since the introduction of
GWLs.24 Brazil and New Zealand have shown similar effects.24–26
Fourth, the adoption of GWLs may create social benefits in diverse ways. However, when
smoking rates drop because of GWLs, governments experience a drop in tax. The
introduction of GWL policies decreases related diseases, and thus ultimately benefits society.
In the case of Canada, the adoption of GWLs has extended the life span, which has yielded a
net benefit of approximately four billion dollars.27 In the case of the United Kingdom, the
introduction of GWLs has resulted in a decrease in the number of smokers by 0.5% and a net
benefit of 206.29 million pounds because of an increase in the economic value of the living
population and the curtailment of medical expenses.28 In Australia, a net benefit of 2.9
billion dollars has been generated because of a decrease in smoking rates, extension of the
life span, improvement in health, the curtailment of medical expenses, and an increase in the
consumption of non-tobacco products.29
Go to:

SEVERAL TASKS FOR THE FUTURE

GWLs are cited as the most cost-effective policy from a diverse set of anti-smoking
policies.30 GWLs are an evidence-based policy whose effect has been proven by countries
that have already adopted them. Consequently, when GWLs are implemented with price
policy that raises tobacco prices, they are expected to effectively decrease smoking rates and
the number of new smokers, and prevent adolescent smoking.18However, several tasks
remain.
First is the task of effective application by the FCTC. The FCTC stipulates within the scope
allowed by the countries respective constitutions, ‘comprehensive ban actions,’ for the
advertisement, and sales promotion and support for tobacco.4 For example, India implements
comprehensive ban actions on advertisements, sales promotions, and support regarding
tobacco in accordance with the FCTC.4 Tobacco advertisements are prohibited on the
broadcast media such as television and radio, and publications such as magazines and
newspapers. On the other hand, signatories of the FCTC have an obligation to implement this
clause by modifying their respective laws and institutions related to the packaging and
labeling of tobacco products within three years of convention ratification.4 Consequently, the
states parties have included health warning messages and graphic labels on at least 30% of
the packaging and have strongly restricted tobacco packaging, which has been used as a
means for marketing tobacco. For example, Australia in October 2011 passed a law that
prohibits the inclusion of advertising statements, images, and company logos on cigarette
packs.4 This law applies so-called ‘plain packaging,’ and thus requires to uniformize the
color of all cigarette packs as drab dark brown and to include chilling images demonstrating
the harm of smoking instead of advertising images and company logos.4 It is fair to say that
the warnings are important for providing useful information to consumers.
Second, developing various and effective GWLs in a sociocultural context and smoking
characteristics for each country is necessary. GWLs mainly affect smokers through fear,
which can yield disparate effects according to the conveyed contents, themes, and messages.
Consequently, the effectiveness and effect of GWLs on smokers for each country must be
analyzed meticulously.
Third, longitudinal studies comparing long-term changes in smoking rates before and after
the introduction of GWLs need to be conducted. In addition, scientifically reviewing both
price policies and various non-price policies that yield the greatest smoking cessation effect is
necessary. Such a task will continuously prove the long-term effect of a policy, and thus
secure the validity of and justification for the introduction of the policy and expand related
future policies. Economic evaluation and cost-benefit analysis must also be conducted. To
meticulously grasp the policy effect, it is necessary to consider whether the goals have been
achieved by adopting GWLs and who are to be the objects of persuasion. Smokers vs. non-
smokers, heavy smokers vs. occasional smokers, and adolescents vs. adults are possible. The
effect of GWLs may be most dramatic for occasional smokers or adolescents in their early to
mid-teenaged years that have not yet started to smoke rather than heavy smokers who have
formed the habit.
Go to:

CONCLUSION
This paper attempted to summarize what is happening globally in terms of GWLs, how
effective the implementation of GWLs is on decreasing tobacco rates, and what the next steps
are for GWLs around the world. The success of an anti-smoking policy can manifests itself as
an effect of individual policies, the rise of tobacco prices, and the introduction of GWLs.
Success need to be evaluated as an integrated effect of diverse policies that includes the rise
of tobacco prices and the extension of non-smoking areas.
Go to:

Footnotes
CONFLICTS OF INTEREST

No potential conflicts of interest were disclosed.

Go to:

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Effects of Strengthening Cigarette Pack Warnings on Attention and
Message Processing: A Systematic Review
Show all authors

Seth M. Noar, Diane B. Francis, Christy Bridges, ...

First Published October 28, 2016 Research Article

https://doi.org/10.1177/1077699016674188

Article information

Abstract

The current study sought to examine the impact of strengthening cigarette pack
warnings on attention, message processing, and perceived effectiveness, through
a systematic review of longitudinal observational studies. The review included 22
studies (N = 81,824 participants). Strengthened warnings increased attention to
warnings, recall of warnings, and thinking about the health risks of smoking.
Strengthened warnings also increased several perceived effectiveness outcomes,
including perceptions that warnings reduce smoking and motivate quitting.
Strengthened cigarette pack warnings achieve their goal of attracting attention
and enhancing motivation to act. Strengthening warning policies should be a
priority for tobacco control globally.

Keywords warning, pictorial, graphic, smoking, global

Tobacco use is the leading cause of preventable disease and death in the world,
causing nearly six million deaths each year (World Health Organization [WHO],
2013). Health effects of tobacco use include noncommunicable diseases such as
cancer, cardiovascular disease, respiratory disease, and reproductive
complications. Tobacco use can also exacerbate communicable diseases like
tuberculosis and respiratory tract infections (U.S. Department of Health & Human
Services, 2004; WHO, 2012). Globally, tobacco use is responsible for 71% of lung
cancer deaths and 42% of chronic obstructive pulmonary disease cases (WHO,
2012). In the United States alone, cigarette smoking causes about one in five
deaths, or more than 480,000 deaths per year (U.S. Department of Health &
Human Services, 2014). Smoking also costs the United States an estimated
US$96 billion in direct health care expenditures and US$97 billion in productivity
losses each year (Centers for Disease Control and Prevention, 2012).

Cigarette pack warnings are a compelling communication strategy (Hammond,

2011). The combination of high exposure, nearly universal reach, and very low
cost has made warnings a core tobacco control strategy globally. Warnings have
evolved through several stages over the past four decades—from simple, vague
messages on the side of packs to rotating messages on the front of packs
focused on specific health effects, often accompanied by color pictures (Hiilamo,
Crosbie, & Glantz, 2014). Current guidance from the WHO Framework
Convention on Tobacco Control (FCTC) calls for large warnings on tobacco
products, with implementation guidance suggesting the addition of pictures (WHO,
2003). While Canada was the first country to implement color pictorial warnings in
2001, by 2015 implementation of pictorial warnings had occurred in 77 countries
and jurisdictions that are home to more than 50% of the world’s population
(Canadian Cancer Society, 2014); an additional 14 countries have finalized
pictorial warnings and are preparing for implementation (Campaign for Tobacco-
Free Kids, 2016). In the United States, the Food & Drug Administration (FDA)
attempted to implement pictorial warnings as outlined in the 2009 Family Smoking
Prevention and Tobacco Control Act (2009). To date, however, implementation
has been thwarted by tobacco industry lawsuits (Kraemer & Baig, 2013).

Our systematic review examines whether strengthening cigarette pack warnings

increases attention, message processing, and perceptions of warning
effectiveness. We define strengthened warnings as cases where countries
improve text warnings, implement pictorial warnings, or improve pictorial
warnings. Strengthening warnings often involves several changes to warnings, as
they are nearly always larger in size, are on the front (and back) of the cigarette
pack, and are typically accompanied by an increase in the number of rotating
warnings (i.e., new warning content). Strengthening warnings may more
effectively motivate quitting smoking while reducing the appeal of the cigarette
 pack itself (Hammond, 2011; Noar, Hall, et al., 2016). However, to date, no
systematic review has examined the impact of countries strengthening warnings
on attention, message processing, and perceptions of warning effectiveness.

Literature Review

According to several communication theories (Kruglanski & Thompson,

1999; McGuire, 1989; Petty & Cacioppo, 1986), attention and cognitive
processing are critical early processes in the attitude and behavior change
process. For example, McGuire’s (1989) persuasion model suggests that the
earliest steps in the persuasion continuum consist of exposure and attention to a
message; if a message is successful in those early-stage processes, later-stage
processes such as attitude and behavior change may occur. Conversely, in the
absence of exposure and attention, a message will fail to have its intended impact
given that the target audience will fail to process it. The elaboration likelihood
model (Petty & Cacioppo, 1981) suggests that cognitive processing is a key
mediating factor that leads to attitude change, with both the type and nature of
cognitive processing affecting the extent to which attitude change may occur.
These and other (Kruglanski & Thompson, 1999) theories suggest that to have an
impact, a message must generate exposure, attract attention, and be processed
by members of the target audience.

In the context of the current study, strengthening cigarette pack warnings—by

enhancing their size, format, or location on the pack—may attract smokers’
attention and elicit message processing. Accordingly, affecting these early-stage
processes is, from a theoretical perspective, a prerequisite for behavior change
(McGuire, 1989; Petty & Cacioppo, 1986); in the absence of such processes, it is
unlikely that warnings will have downstream population-level effects on attitude,
intention, and behavior change. Based on previous work in this area (Hammond,
2011; Noar, Hall, et al., 2016), we pose the following hypothesis:

 H1: Strengthening cigarette pack warnings will increase attention and

message processing.

The current review also examines whether smokers perceive that cigarette pack
warnings have impact. A growing literature in communication (Brennan, Durkin,
Wakefield, & Kashima, 2014; K. C. Davis, Nonnemaker, Duke, & Farrelly,
2013; Dillard, Weber, & Vail, 2007) demonstrates the utility of perceived message
effectiveness, which are target audience perceptions of the persuasive potential of
a message (Dillard et al., 2007). While perceived message effectiveness has
been theoretically under-conceptualized (Yzer, LoRusso, & Nagler, 2015), such
ratings of the persuasiveness of messages are widely used across extant health
communication studies (Yzer et al., 2015), including cigarette pack warnings
(Noar, Hall, et al., 2016). Perceived effectiveness is commonly applied during
message pretesting (Atkin & Freimuth, 2013) in its prospective form, as a gauge
of the potential future effectiveness of a message (i.e., How much would this
message motivate you to quit smoking?). Studies demonstrate that warnings vary
greatly on perceived message effectiveness, and such data are used to choose
particular warnings for implementation (Huang, Thrasher, Reid, & Hammond,
2016; Nonnemaker, Choiniere, Farrelly, Kamyab, & Davis, 2015). Evidence that
messages rated more highly on perceived effectiveness have greater impact on
attitudes (Dillard et al., 2007), behavioral intentions (K. C. Davis et al., 2013), and
even behavior (Brennan et al., 2014) suggest that perceived message
effectiveness may have predictive validity.

Perceived message effectiveness can also be applied retrospectively, by asking

participants how much they think a given message has affected them (i.e., In the
past 30 days, how much has the warning on your cigarette pack motivated you to
quit smoking?). While lab-based experimental warning studies have commonly
used prospective perceived effectiveness (Noar, Hall, et al.,
2016), retrospective perceived effectiveness has tended to be applied in the
observational literature. Such studies examine the extent to which
people believe the warnings on their cigarette packs have made them think about
the health risks of smoking, motivated them to try and quit, or led them to forego
cigarettes. Based on previous work (Hammond, 2011; Noar, Hall, et al., 2016), we
pose the following hypothesis:

 H2: Strengthening cigarette pack warnings will increase perceived message

effectiveness.

Meta-analysis of experimental studies has demonstrated that pictorial cigarette

pack warnings are superior to text warnings in attracting attention and stimulating
cognitive elaboration, and they are consistently perceived as more effective than
 text warnings (Noar, Hall, et al., 2016). However, the ecological validity of these
studies remains uncertain due to the fact that they typically consist of single
exposures to warnings on a computer screen (but not smokers’ own packs), in the
context of an experimental paradigm. However, for an examination of real-world
impact, a synthesis of population-level studies is needed. Longitudinal
investigations have examined warning effects when countries have strengthened
their warning policies; while, in many cases, this constitutes a change from text to
pictorial warnings, some countries have strengthened text warnings (e.g., moved
text from side to front of pack) or strengthened pictorial warnings (e.g., increased
their size).

The purpose of our study was to evaluate the longitudinal impact of strengthened
cigarette pack warnings by cumulating the findings of longitudinal observational
studies. By synthesizing this global literature, we sought to understand whether
strengthening cigarette pack warnings impacts warning attention, message
processing, and perceived effectiveness.

Method
Search Strategy

We used a comprehensive search strategy to locate studies relevant to this

systematic review. The search strategy involved five steps. First, we searched
PsycINFO, PubMed, Embase, Web of Science, and Business Source Complete
computerized databases in February 2014. We used the following terms:
(cigarette* OR tobacco) AND (warning* OR label* OR pictorial OR graphic).
Second, we examined the reference sections of six narrative reviews of cigarette
pack warnings (Centers for Disease Control and Prevention, 2011; R. Davis,
Gilpin, Loken, Viswanath, & Wakefield, 2008; Hammond, 2011; Hammond,
Wakefield, Durkin, & Brennan, 2013; Monarrez-Espino, Liu, Greiner, Bremberg, &
Galanti, 2014; National Cancer Institute, 2009). Third, we examined the reference
lists of the final set of articles included in our review. Fourth, we searched the first
100 results of our search terms in both Google Scholar and Google. Fifth, we
contacted the authors of the final set of articles and posted on five health
communication and tobacco listservs (e.g., Society for Research on Nicotine and
Tobacco) to request additional published or unpublished studies. All studies were
considered for inclusion—including unpublished/gray literature as well as non-
English study reports.

The review had three inclusion criteria. First, a study had to be observational and
report data on the impact of a change in the implementation of national cigarette
pack warning policy. Second, a study had to report data from at least one
assessment (self-report or otherwise) before the change in warning policy and at
least one assessment during or after implementation of the change. Third, a study
had to report one or more outcomes from the attention and recall, warning
reactions, social reactions, or perceived effectiveness categories from
the message impact framework (Noar, Hall, et al., 2016). Studies that assessed
knowledge, attitudes/beliefs, and behaviors were excluded as they were the basis
for a separate, companion review article (Noar, Francis, et al., 2016).

Two trained reviewers independently examined all study titles for the 6,241
references we identified (Figure 1), reducing the number to 1,215. They then
reviewed abstracts, further reducing the number to 87. During this process, we
excluded articles only if both reviewers independently determined the article to not
be relevant. The two reviewers independently examined the full text of 87 articles
and tracked reasons for study exclusion. If the two reviewers made a different
determination about a particular article classification, they consulted with a third
referee to resolve the discrepancy (by discussing the disagreement and allowing
the third referee to weigh in) and make a final determination. This process
identified 21 articles reporting on 22 independent samples.
Figure 1. PRISMA flow diagram showing the study screening process.

Article Coding
Study characteristics

Two authors independently coded all articles on several features relevant to this
review, including study characteristics such as country of policy change and
control country (if any) and sample characteristics such as age range, income
level, and smoking status (Online Appendix 1). The researchers also coded study
design characteristics such as sample size, sampling and data collection mode,
response rate, and design type (Online Appendixes 1 and 2), as well as warning
policy characteristics such as previous warning description, new warning
description, dates of policy implementation, number of warnings on pack, and
whether the new warnings met WHO warning criteria (Online Appendix 3).
 All discrepancies between coders were resolved through discussion between the
two coders and the first author. We calculated intercoder reliability for each
characteristic. Most categories had perfect agreement, and mean Cohen’s kappa
was .93.

Summarizing study findings

We developed a list of outcome variables assessed in warning label studies, with

definitions for each, based on the literature and our previous work in this area
(Noar, Hall, et al., 2016). We summarized the main results of studies on each of
these outcome variables, noting which findings were statistically significant
(Online Appendix 4). For the few studies that did not report significance tests
(Agar, Craig, Fong, & Quah, 2014; Environics Research Group,
2005; Fathelrahman et al., 2013; Wardle et al., 2010; Zhang et al., 2011), we
computed significance tests when the necessary data were reported (Lipsey &
Wilson, 2001).

Pooled results

We extracted quantitative data directly before and after warning implementation in

cases where we had five or more observations and where data were reported in a
form that allowed for synthesis. These data represented pre–post changes in
intervention countries only. For studies that assessed a construct with multiple
measures (e.g., two measures of attention), we averaged the measures together.
Also, the extracted data represented the top two response categories of a given
variable, as these data were nearly always reported. For example, for attention
in Hammond et al. (2007), we extracted the percentage of people who said they
noticed or read the warnings “often” or “very often,” the top two response
categories in the Likert-type response scale (Hammond et al., 2007). For each
outcome, we weighted the before, after, and difference proportions by their
inverse variance using the logit method and computed random-effects meta-
analytic models (Lipsey & Wilson, 2001).

When reporting results, we organized outcome variables using the message

impact framework (Figure 2). The first group of outcomes (attention/recall)
consisted of awareness of warning policy change, attention to warnings, and
unaided recall (i.e., asking participants what the warnings say, with no prompts or
 cues). The second group of outcomes (warning reactions) consisted of credibility,
cognitive elaboration, negative affective reactions, and avoidance. A third group
consisted of social interactions. Finally, perceived effectiveness consisted of a
number of perceptions of the warnings—namely, whether they were easy to
understand, provided information, caused reactance, enhanced cognitive
elaboration, made smoking less attractive, decreased the likelihood of smoking,
increased motivation to quit or stay quit, led to foregoing of cigarettes, and were
generally effective. We characterized a change as an increase or decrease that
was statistically significant (p < .05) in the original study or in our own
calculations.

Figure 2. Message impact framework showing outcomes assessed in the set of

studies.

Results

The 22 studies were published between 1997 and 2014, with a median publication
year of 2011. Studies were conducted in 11 different countries; the most common
were Australia (26%), the United Kingdom/England (20%), Canada (14%), and
the United States (12%). The United States was always included as a control
country; the next most common control country was Canada (three of five were as
a control). All but a single study examined one intervention country; the remaining
study had two intervention countries (Borland et al., 2009). While most studies
(72%) had no control country, 14% had one, 4% had two, and 10% had three
control countries (Table 1).

Table 1. Characteristics of Studies (k = 22) in the

Systematic Review.

Table 1. Characteristics of Studies (k = 22) in the Systematic Review.

View larger version

Most studies (96%) used probability sampling. The most common data collection
mode was phone (50%) followed by in-person interview (26%). The most common
data type was panels (same participants over time; 50%) or multiple cross-
sectional (36%); 14% used both types of data. The cumulative sample size across
 all studies was N = 81,824. Studies most commonly examined young
adults/adults (50%), although 32% of studies also included adolescents. Only
14% of studies were solely adolescents. While just under half (46%) of studies
were of smokers, 50% were of both smokers and nonsmokers, and 4% were of
former smokers. Only 18% of studies reported including low-income participants.

The most common policy change was from text to pictorial warning (67%). One
study, however, examined the change from pictorial to strengthened pictorial
warning (4%), when Australia increased the size of their pictorial warnings from
30% to 75% of the pack face (Zacher et al., 2014). Other studies (29%) examined
the change from text to strengthened text, such as when the United Kingdom
strengthened text from 6% to 30% on the front and from 6% to 40% on the back of
the pack (Hammond et al., 2007). Only one study (of Australia) examined the
implementation of plain packs along with strengthened pictorial warnings (Zacher
et al., 2014).

When countries implemented new warnings, they also tended to increase the
number of warnings that rotated on packs. The mean number of warnings pre–
policy change was 5.92 (SD = 2.84), whereas post–policy change, it was 10.79
(SD = 8.6). Policy changes typically allowed countries to meet the WHO warning
criteria. That is, after policy changes took place, all countries had warnings in the
country’s principal language and on the front and back of packs, while 91%
covered at least 30% of the pack and 68% had color pictorials. Also, while English
was the most common language for warnings (55%), several warnings were in
other languages (23%) or appeared in both English and another language (18%).

Studies ranged from a low of two data points (58%) to a high of nine data points
(4%). The mean number of data points across studies was 3.00 (SD = 1.69),
whereas the mean number of months between data points was 12.00 (SD = 6.67).

Effects of Warning Policy Changes

Attention and recall

Three studies—from Australia, Canada, and Iran—assessed awareness of the

warning policy change. Awareness increased in Australia after strengthening text
warnings in 1995 (Borland & Hill, 1997), as well as in Canada (Environics
 Research Group, 2005) and Iran (Heydari, Ramezankhani, & Talischi, 2011) after
implementation of pictorial warnings in 2001 and 2009, respectively (Table 2).

Table 2. Impact of Change in Cigarette Pack Warning

Policy: Attention and Message Processing.

Table 2. Impact of Change in Cigarette Pack Warning Policy: Attention and Message
Processing.

View larger version

Eighteen studies assessed one or more forms of attention, and 15 studies showed
increases in attention to the warnings. Fourteen studies assessed attention in the
form of noticing the warnings, of which 12 showed increases in noticing. Noticing
the warnings increased after implementation of pictorial warnings in eight studies
(Chang, Chung, Yu, & Chao, 2011; Environics Research Group, 2005; Hammond
et al., 2007; Miller, Quester, Hill, & Hiller, 2011; Partos, Borland, Yong, Thrasher,
& Hammond, 2013; Thrasher, Perez-Hernandez, Arillo-Santillan, & Barrientos-
Gutierrez, 2012; Wardle et al., 2010; Yong et al., 2013) and after strengthening
text warnings in four studies (Agar et al., 2014; Borland, 1997; Hassan, Shiu,
Thrasher, Fong, & Hastings, 2008; Li et al., 2014).

Of the nine studies assessing looking at and reading the warnings, seven
observed increases, one observed a decrease, and one observed no change. For
instance, looking at and reading the warnings increased after Australia (White,
Webster, & Wakefield, 2008), Mexico (Thrasher et al., 2012), Thailand (Yong et
al., 2013), and the United Kingdom/England (Moodie, Mackintosh, & Hastings,
2013; Wardle et al., 2010) implemented pictorial warnings, as well as after China
strengthened text warnings (Agar et al., 2014). Three studies assessed a
composite of noticing, looking at, and reading the warnings (Borland et al.,
2009; Fathelrahman et al., 2013; Zhang et al., 2011); two of the studies observed
increases (Borland et al., 2009; Zhang et al., 2011). Across all forms of attention
in 16 studies that provided suitable data, attention increased from 38% before
implementation to 56% after implementation of strengthened warnings (Figure 3).
This represented a statistically significant absolute increase of 16% (47% relative
increase), which was statistically heterogeneous, indicating variability among the
effect sizes (Table 3).
Figure 3. Attention to warnings before and after implementation of strengthened
warnings.

Table 3. Effectiveness of Strengthening Cigarette Pack

Warnings: Mean Weighted Effect Sizes.

Table 3. Effectiveness of Strengthening Cigarette Pack Warnings: Mean Weighted

Effect Sizes.
 View larger version

Three studies assessed unaided recall of the warnings, and all three studies
showed increases in unaided recall of some text and pictorial warnings (Borland &
Hill, 1997; Miller et al., 2011; Moodie et al., 2013). Typically, recall
of new warnings increased in these studies, whereas recall of warnings that were
phased out or retained from older warnings decreased. For example, unaided
recall that new warnings had text that said smoking causes emphysema, mouth
and throat cancer, and peripheral vascular disease; smoking clogs your arteries;
and smoking is a leading cause of death all increased after Australia implemented
their first set of pictorial warnings in March 2006 (Miller et al., 2011). Miller et al.
(2011), however, found decreases in unaided recall (of older warnings) that had
text that said smoking causes heart disease and lung cancer after Australia
implemented their second set of pictorial warnings in November 2006. Moodie et
al. (2013) observed that unaided recall that warnings had (new) images of
healthy/diseased lungs, rotten teeth, and neck tumors increased after the United
Kingdom implemented pictorial warnings in 2008, whereas unaided recall that
warnings had text (retained in the newer warnings) that said smoking kills and
smoking seriously harms you and others around you decreased. Unaided recall of
 the quitline number, assessed in one study, increased in Australia after
implementation of pictorial warnings in 2006 (Miller et al., 2011).

Warning reactions

Three studies assessed credibility (believability and perceived truthfulness), all

from the United Kingdom/England (Moodie et al., 2013; Wardle et al.,
2010). Moodie et al. (2013) found mixed results: Perceived truthfulness of the
warnings increased, but believability did not increase after the United Kingdom
implemented pictorial warnings in 2008. Wardle et al. (2010) found no change in
perceived truthfulness among adults or adolescents after England implemented
pictorial warnings in 2008.

Seven studies assessed cognitive elaboration, including thinking about the

warnings, thinking about smoking harms, and thinking about quitting. Cognitive
elaboration increased in three of seven studies (Moodie et al., 2013; Wardle et al.,
2010; White et al., 2008), and decreased in one study (Hassan et al., 2008).
There were no changes in three studies (Borland, 1997; Silpasuwan et al.,
2008; Wardle et al., 2010). Studies that did see increases were in the wake of
implementation of pictorial warnings in Australia (White et al., 2008), England
(Wardle et al., 2010), and the United Kingdom (Moodie et al., 2013). Across five
studies that provided suitable data, cognitive elaboration increased from 21%
before implementation to 29% after implementation of strengthened warnings
(Figure 4). This represented a statistically significant absolute increase of 7%
(38% relative increase), which was statistically heterogeneous, indicating
variability among the effect sizes (Table 3).
Figure 4. Cognitive elaboration before and after implementation of strengthened
warnings.

Only one study assessed negative affective reactions. Wardle et al.

(2010) observed an increase in worry that smoking may damage future health and
no change in worry that smoking would lower quality of life after the United
Kingdom implemented pictorial warnings in 2008.

Avoidance of the warnings increased in seven of eight studies (Borland et al.,

2009; Fathelrahman et al., 2010; Wardle et al., 2010; Yong et al., 2013; Zacher et
al., 2014; Zhang et al., 2011). For example, Zacher et al. (2014) found that
concealing the pack and putting the cigarette in a case or tin increased after
Australia strengthened pictorial warnings and implemented plain packaging in
2012. Two studies from Thailand assessed avoiding looking at the warnings, and
both found increases after implementation of pictorial warnings in 2005
(Fathelrahman et al., 2013; Yong et al., 2013). However, Agar et al. (2014) did not
 find changes in avoiding (looking at and thinking about) the warnings after China
strengthened text warnings in 2008.

Social interactions

Two studies assessed social interactions, both using adolescent samples. One
study from Australia found an increase in talking about the warnings after
implementation of pictorial warnings in 2006 (White et al., 2008). A study from the
United Kingdom did not find changes in talking after implementation of pictorial
warnings in 2008 (Moodie et al., 2013).

Perceived effectiveness

Sixteen studies assessed one or more forms of perceived effectiveness (Table 4).
Perceptions that the warnings were easy to understand—assessed in two
studies—decreased among adults in England but did not change among
adolescents after implementation of pictorial warnings in 2008 (Wardle et al.,
2010). The perception that the warnings provide information about the risks of
smoking—assessed in two studies—increased among adults in England but did
not change among adolescents after implementation of pictorial warnings in 2008
(Wardle et al., 2010). Perceptions that the warnings are unnecessary—assessed
in two studies—decreased among adults in England but did not change among
adolescents after implementation of pictorial warnings in 2008 (Wardle et al.,
2010). Among adolescents in Australia, White et al. (2008) found no change in
perceived effectiveness of the warnings to make me have a cigarette—an
indication of reactance behavior—after implementation of pictorial warnings in
2006.

Table 4. Impact of Change in Cigarette Pack Warning

Policy: Perceived Effectiveness.

Table 4. Impact of Change in Cigarette Pack Warning Policy: Perceived

Effectiveness.
 View larger version

Thirteen studies assessed perceived effectiveness of the warnings to make me

think about quitting or about smoking harms (perceived effectiveness—cognitive
elaboration). Of those, 11 studies showed increases (Borland et al., 2009; Chang
et al., 2011; Hammond et al., 2007; Hassan et al., 2008; Partos et al.,
2013; Thrasher et al., 2012; Wardle et al., 2010; White et al., 2008; Yong et al.,
2013; Zhang et al., 2011). For example, perceived effectiveness of the warnings
to make me think about quitting smoking increased after implementation of
pictorial warnings in Taiwan, Mexico, and Australia (Chang et al., 2011; Thrasher
et al., 2012; Wardle et al., 2010; White et al., 2008) and strengthened text
warnings in the United Kingdom/England (Hammond et al., 2007; Hassan et al.,
2008). Perceived effectiveness of the warnings to make me think about the health
risks of smoking increased after implementation of pictorial warnings in Taiwan
(Chang et al., 2011), Australia (Partos et al., 2013), Mexico (Thrasher et al.,
2012), and Thailand (Yong et al., 2013). Across the nine studies that provided
suitable data, perceived effectiveness—cognitive elaboration increased from 31%
before implementation to 45% after implementation of strengthened warnings
(Figure 5). This represented a statistically significant absolute increase of 14%
(45% relative increase), which was statistically heterogeneous, indicating
variability among the effect sizes (Table 3).
Figure 5. Perceived effectiveness—Cognitive elaboration before and after
implementation of strengthened warnings.

Wardle et al. (2010) found increases in perceptions that the warnings make
smoking seem less attractive among adult and adolescent samples in England
after implementation of pictorial warnings in 2008. Perceptions that the warnings
make people smoke less or discourage people from smoking increased among
adolescents after the United Kingdom/England implemented pictorial warnings in
2008 (Moodie et al., 2013). Perceptions that the warnings had no impact on
smoking behavior decreased among both adolescents and adults (Wardle et al.,
2010).

Perceived effectiveness of the warnings to motivate quitting or maintenance of

quitting increased in four of five studies (Agar et al., 2014; Partos et al.,
2013; Silpasuwan et al., 2008; Wardle et al., 2010; Yong et al., 2013). For
example, perceived effectiveness of the warnings to make one want to quit
smoking increased after Thailand implemented pictorial warnings in 2005
(Silpasuwan et al., 2008; Yong et al., 2013). Perceived effectiveness of the
warnings to make one stay quit also increased after China strengthened its text
warnings in 2008 (Agar et al., 2014). However, Wardle et al. (2010) found that
perceived effectiveness of the warnings to make one want to quit did not change
among adults in England after implementation of pictorial warnings in 2008.

Perceived effectiveness of the warnings to make one forego cigarettes increased

in eight of 10 studies (Borland, 1997; Borland et al., 2009; Hammond et al.,
2007; Hassan et al., 2008; Wardle et al., 2010; White et al., 2008; Yong et al.,
2013; Zhang et al., 2011). For instance, perceived effectiveness to make one
forego cigarettes increased after Thailand (Yong et al., 2013), Australia (Borland
et al., 2009; White et al., 2008; Zhang et al., 2011), and England (Wardle et al.,
2010) implemented pictorial warnings in 2005, 2006, and 2008,
respectively. Fathelrahman et al. (2013), however, observed no change in
perceived effectiveness to increase foregoing after Thailand implemented pictorial
warnings in 2005. Across the nine studies that provided suitable data, perceived
effectiveness—foregoing increased from 18% before implementation to 23% after
implementation of strengthened warnings (Figure 6). This represented a
statistically significant increase of 4% (28% relative increase), which was
statistically heterogeneous, indicating variability among the effect sizes (Table 3).
Figure 6. Perceived effectiveness—Foregoing before and after implementation of
strengthened warnings.

Discussion

Across this international body of literature, we found significant support for the
proposition that enhancing cigarette warnings increases warning attention and
stimulates message processing. We also found significant support for the notion
that strengthening cigarette warnings increases perceptions of warning
effectiveness. These findings strongly suggest that the way in which we
communicate with smokers about the health risks of smoking is consequential;
that is, strengthening warnings appears to fundamentally change the way in which
smokers attend to, process, and perceive the warning information on their packs.

A key first goal of any health message is to gain attention, as message exposure
is critical for garnering effects (McGuire, 1989; Niederdeppe, Avery, Byrne, &
Siam, 2014). Our results strongly suggest that strengthening warnings increases
attention at the population level. While most of the evidence in our review comes
from countries that newly implemented pictorial warnings, there was also
evidence that strengthening text warnings (e.g., moving from side to front of pack
and increasing size) may increase attention. Furthermore, although our pre–post
effects were fairly dramatic, studies demonstrate that attention to warnings
ultimately decreases over time as smokers become habituated to warning content
(Borland et al., 2009; Hammond et al., 2007; Hitchman, Driezen, Logel,
Hammond, & Fong, 2014). However, even with these reductions, research
suggests attention levels remain higher than they were before implementation of
strengthened warnings (Borland et al., 2009; Hammond et al., 2007). Moreover,
given that countries are likely to make only a limited number of major warning
policy changes, another way to increase attention to warnings may be to rotate in
a new set of warnings under the current policy. This may help sustain the effects
of cigarette warnings over time (Abascal et al., 2012; Miller et al., 2011).

We also saw effects of strengthened warnings on message processing. One key

effect that we observed was on cognitive elaboration, which refers to thinking
about the warnings, the health effects of smoking, or of quitting. We also saw
clear effects on perceived effectiveness—cognitive elaboration. The distinction we
draw is that cognitive elaboration refers to smokers’ reports of thinking about the
warnings, harms of smoking, or quitting. In contrast, the perceived effectiveness
variable refers to smokers’ reports that the warnings made them think about these
topics; that is, the participant is asked to make an attribution about the impact of
the warning. While we found effects on both impact and perceived impact, effects
were larger for perceivedcognitive elaboration. It may be that
smokers’ perceptions of elaboration (perceived effectiveness) were
overestimates, and that cognitive elaboration is a more accurate assessment of
this variable. This interpretation is consistent with our previous experimental meta-
analysis of pictorial warnings in which we found that the perception that warnings
motivate “me” to quit smoking was larger than actual changes in quit intentions
sparked by the warnings (Noar, Hall, et al., 2016). The cognitive elaboration
findings are important given that several studies have illustrated that (perceptions
of) cognitive elaboration may mediate the effects of warnings on quit attempts
(Brewer et al., 2016; Fathelrahman et al., 2013; Thrasher, Abad-Vivero, et al.,
2016).
Our results also consistently demonstrated that strengthened warnings increased
avoidance. Avoidance can take many forms, including trying not to look at or think
about the warnings, as well as behaviors such as covering up the warnings or not
buying packs with particular warnings on them. What is intriguing is that avoiding
warnings does not appear to be an indicator that they are ineffective, and it may
even be a marker for impact. For instance, several studies have provided
evidence that avoidance does not undermine the efficacy of pictorial cigarette
warnings, finding a similar impact of warnings among both avoiders and
nonavoiders (Hammond, Fong, McDonald, Brown, & Cameron, 2004; Peters et
al., 2007). Moreover, one recent study found that avoidance was
significantly positively associated with attention to warnings, cognitive elaboration,
plans to quit, and quit attempts (Thrasher, Abad-Vivero, et al., 2016). Thus, while
avoidance has not, on its own, been identified an indicator of warning
effectiveness, it does not appear to undermine effectiveness, and in some cases,
it may be an indicator that a warning is having impact.

We saw consistent findings of the impact of strengthened warnings on a range of

perceived effectiveness outcomes. Participants perceived that strengthened
warnings (a) provided information about the risks of smoking, (b) were necessary,
(c) made one think about smoking health risks, (d) made smoking less attractive,
(e) decreased the likelihood of smoking, (f) increased quit motivation, and (g)
made one more likely to forego cigarettes. Virtually all of these findings were in
countries that newly implemented pictorial warnings, and they illustrate the value
that smokers themselves see in pictorial cigarette pack warnings. Although it is
unclear whether perceived effectiveness plays a direct role in the attitude and
behavior change process, prospective perceived effectiveness assessments
appear to provide valuable information about messages (Huang et al., 2016). For
example, at the aggregate level, messages that are rated as more effective are
more likely to have greater impact on attitudes (Dillard et al., 2007), quit intentions
(Bigsby, Cappella, & Seitz, 2013; K. C. Davis et al., 2013), and smoking behavior
(Brennan et al., 2014). While the meaning of retrospective perceived effectiveness
measures is less clear, the fact that so many of them increased (concomitant with
strengthening warnings) adds to the evidence that strengthening warnings
increases their impact (Hammond, 2011; Noar, Hall, & Brewer, 2015; Noar, Hall,
et al., 2016). The increases we observed suggest that such measures tell us
something meaningful; indeed, it may be that messages that perform poorly on
 perceived effectiveness have little chance of having actual impact on individuals
or populations, while higher (aggregate) perceptions of effectiveness are an
indicator that messages are likely to have impact. These findings are consistent
with experiments that have briefly exposed participants to pictorial warnings in
controlled experiments and found increases across a range of perceived
effectiveness outcomes (Noar, Hall, et al., 2016).

The meta-analyses we report here provide additional precision as to the size of

effects that may result from strengthening warnings. They also revealed
heterogeneity of effects across studies and countries; this indicates the need for
future research to better understand what factors may lead to greater impact (e.g.,
particular changes in warning size, content, or format; particular samples or
subgroups for which warnings work best). Moreover, the results of the current
review, in concert with our companion review (Noar, Francis, et al., 2016),
suggest that warnings may have impact according to a hierarchy-of-effects as
proposed by McGuire (1989). The current study found that after implementation of
strengthened warnings, attention had an absolute increase of 18% and cognitive
processing increased 7% to 14%. Our companion review suggests that after
implementation of strengthened warnings, quit attempts had an absolute increase
of 4% and smoking prevalence decreased by 2% (Noar, Francis, et al., 2016). At
the population level, these are important effects. However, these data suggest
that warnings may operate according to a hierarchy-of-effects, with the largest
increases in attention and message processing and smaller impact on smoking
behaviors. One implication of this is the importance of maximizing attention and
messaging processing of warnings given the apparent reduced level of impact at
each stage of the hierarchy. Such a hierarchy-of-effects is consistent with effects
observed in recent large-scale smoking cessation campaigns (McAfee, Davis,
Alexander, Pechacek, & Bunnell, 2013).

Implications for Global Warning Policy

Our findings, as well as other recent work (Brewer et al., 2016; Noar, Francis, et
al., 2016; Noar, Hall, et al., 2016), strongly suggest that strengthening warning
policies should be a priority for tobacco control globally. While at least 77
countries and jurisdictions have implemented pictorial warnings (Canadian Cancer
Society, 2014), many countries still have weak warning policies. Countries that
 have weaker text warnings should implement larger, more prominent warnings on
the front and back of the pack, preferably accompanied by graphic images (i.e.,
pictorial warnings). This includes the United States where implementation of
federal law requiring pictorial warnings has been stalled by tobacco industry
lawsuits (Kraemer & Baig, 2013). In addition, the many countries with pictorial
warnings should consider ways to strengthen those warnings, including increasing
their size and ensuring that a quitline number is prominently featured on the
cigarette pack (Miller, Hill, Quester, & Hiller, 2009; Noar, Francis, et al., 2016).

Countries across the globe are also innovating their cigarette packaging policies,
and this is a promising trend. For example, in 2012, Australia became the first
country in the world to implement a “plain packaging” policy where cigarette packs
no longer have brand imagery and a large pictorial warning covers most of the
face of the pack (Zacher et al., 2014). Uruguay (in 2010) banned differentiated
branding such that each tobacco company can only distribute one type of
cigarettes (i.e., no sub-brands), in an attempt to reduce the perception that some
cigarette types are less harmful than others (Abascal et al., 2012). Finally, in
addition to being the first country to implement color pictorial warnings in 2001,
Canada has now required cigarette pack inserts with messages encouraging
smokers to quit (Thrasher, Swayampakala, et al., 2016). These and other
innovations are important steps forward in strengthening labeling policy and
ultimately reducing tobacco’s global burden of disease and death.

Limitations

A key limitation of our review was that studies were observational in nature; thus,
it is possible that other unknown factors contributed to changes in variables
assessed in these studies, and most studies had no comparison groups. Although
these study designs reduced our ability to make firm causal conclusions, the real-
world context of the studies is a strength, as previous meta-analytic work has only
demonstrated the efficacy of pictorial warnings in controlled experimental contexts
(Noar, Hall, et al., 2016). Our review extends this previous work by demonstrating
the longer term impact of warnings after real-world implementation in numerous
countries. Another limitation has to do with variations in researchers’ selection,
conceptualization, and measurement of outcome variables (including timing of
measurement), which may contribute to additional between-study variability in
 findings. Studies varied greatly with regard to the number of outcomes assessed,
and thus, varying levels of data were available for different outcomes of interest.
This limitation lessened our ability to make firm conclusions about some variables,
such as negative affect (assessed in one study) and social interactions (assessed
in two studies), in the context of policies strengthening cigarette pack warnings.

Conclusion

Cigarette pack warnings, especially pictorial warnings, are an important global

tobacco control policy. Our review suggests that strengthening cigarette pack
warnings increases attention to warnings, message processing, and perceptions
of warning effectiveness. Strengthening cigarette pack warnings should be a
priority for tobacco control globally, including in the United States where federal
law requires implementation of pictorial warnings on cigarette packs.

Acknowledgements

The authors thank Stephanie Lane for her assistance locating and screening
studies for the review. They also thank the following people for providing
additional data for this systematic review: Ron Borland, Ahmed Fathelrahman,
James Thrasher, and Victoria White.

Authors’ Note
The content is solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health (NIH) or the Food &
Drug Administration (FDA).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Research reported in this publication
was supported by P30CA016086 from the National Cancer Institute and the Food
& Drug Administration (FDA) Center for Tobacco Products (CTP).
DO GRAPHIC HEALTH WARNINGS ON CIGARETTE PACKS
WORK?
By: Angelle Braganza, Knulp Aseo, Monique Danao Inquirer Volunteer Corps / 11:45
PM December 09, 2016
Graphic health warnings are effective in prompting smokers who buy on per-stick basis
to think about the dangers of smoking, which in turn, is associated with increased
intention to quit smoking.

This is among the findings of a study conducted by research students of the University of
the Philippines in Diliman.

The researchers surveyed 402 Quezon City smokers and conducted two focus group
discussions from October to November 2016 to find out how the graphic health warnings
on cigarette packs had affected smoking behavior of Filipinos, given the fact that buying
tingi, or on a per-stick basis, is prevalent in the Philippines.

The results suggest that thinking about the dangers of smoking is the strongest factor
correlated with the intention to change cigarette consumption, especially among tingi
buyers.

In other words, the more smokers think about the dangers of cigarette smoking, the
more likely they are to think about quitting.

This is where the graphic health warnings show their strongest impact: Smokers who are
more afraid of the graphic health warnings think more about the dangers of smoking.

Figure 1: The respondents were asked regarding the salience of dangers of smoking in
their minds (“Napapaisip po ba kayo sa mga sakit na maaring maidulot ng
paninigarilyo?”) and their fear of the graphic health warnings (“Gaano po kayo
nababahala sa mga nakikita niyong larawan sa pakete ng sigarilyo?”). Graphics by
Danielle Quililan, Erricka Calvelo
One explanation suggests that the warnings prompt the smokers to think that they could
contract the diseases depicted in the pictures.

One informant said, “Natatakot (ako) dahil baka po mangyari (sa akin).”

(“I’m afraid because it may happen to me.”)

Pack buyers prefer TV for smoking information

The case is different for smokers who buy cigarettes by pack.

Among pack buyers, the results suggest that correct knowledge of smoking-related
diseases is the strongest factor correlated with the intention to quit smoking.

In other words, the more knowledgeable they are about smoking-related diseases, the
more likely they are to quit smoking.

Graphic health warnings only ranked as the second to television as most cited source of
information about the dangers of smoking.

A big majority of both per-stick and pack buyers – 94.8 percent – had seen the graphic
warnings on cigarette packs. But some of them said they did not really pay attention to
the pictures and just threw away the packs.

Some respondents said that they were scared and disgusted by the pictures to the point
that they would prefer throwing the packs away rather than looking at them.
Figure 2: Cited sources of information regarding smoking-related health risks. Graphics
by Danielle Quililan, Erricka Calvelo
However, statistical analysis from the study suggests that newspapers and the internet
were the biggest contributors to knowledge of dangers of smoking among pack-buyers.
Even if the smokers watched programs about smoking on television more often, they got
more information from the things they had read on newspapers and saw on the internet.

Studies about mass media consumption suggest that reading is an active way of media
consumption that induces higher engagement from people. Highest engagement is
expected to increase recall of the information read.

So those who read about smoking-related health risks from media, such as newspapers
and the internet, are expected to remember more information.

Legal scare tactic

Since being implemented last March 2016, the Graphic Health Warning Law (Republic
Act 10643) has made its greatest contribution to Quezon City smokers by raising their
awareness about and making them fear smoking-related health risks, a finding
supported by the UP Diliman communication research study.

The law requires cigarette manufacturers to print graphic health warnings featuring
depictions of the many health risks of tobacco use, such as cancer, stroke and heart
disease, among many others, on 50 percent of the front and back panels of cigarette
packs.
Figure 3: Some provisions of the Philippine Graphic Health Warning law. Graphics by
Danielle Quililan, Erricka Calvelo
These graphic warnings are expected to instill fear of the dangers of cigarette smoking
to discourage smokers them from continuing their habit.

Printing of graphic health warnings on cigarette packs was one of the non-price
measures suggested to lessen cigarette consumption around the world, based on the
World Health Organization Framework Convention on Tobacco Control (WHO FCTC), in
which the Philippines is a signatory.

According to the Canadian Cancer Society 2016 International Status Report about
cigarette package health warnings, at least 105 countries and jurisdictions have already
implemented laws that mandate the inclusion of pictorial warnings on cigarette packs.

Four Asean countries – Thailand, Brunei, Laos, and Vietnam – are those that
implemented laws requiring the largest pictorial warnings on packs.

For the Philippines, the implementation of the law is aimed at reducing the number of
Filipino smokers. According to the 2009 Global Adult Tobacco Survey, 28 percent of
Filipino adults – or 17.3 million smokers nationwide – are smokers. Even the youth are
part of the smoking population, with almost one in four Filipino children aged 13 to 15
years old engaged in smoking.
Given this large smoking population, the high incidence of smoking-related diseases in
the country is no surprise.

In 2009, the WHO reported that smoking-related diseases were responsible for 87,600
deaths in the Philippines every year.

Governments losses in health care expenses and productivity costs related to smoking
reached P461 billion in 2006, according to a study conducted by WHO with the
Department of Health (DOH), the University of the Philippines-Manila, Tobacco Free
Initiative, and the Philippine College of Medical Researchers Foundation.

Profile of Quezon City smokers

The UP Diliman communication research study was able to draw some characteristics of
smokers in Quezon City.

On average, smoking for them has become a lifelong habit, starting at the age 19. Some
started smoking as young as five years old.

“Nag-umpisa ng pa-hits hits lang. Tapos tuloy-tuloy na” one informant said.

(“They started with a puff now and then. Then they got hooked.”)

The majority of respondents – 51.7 percent – said they had been influenced to start
smoking. Surprisingly, for most of them – or 52.5 percent – did not live with another
smoker in their immediate household. They are the sole smoker in their homes. The
most cited influence were their peers, with 60.5 percent of them following the lead of
their classmates and 19.8 percent following co-workers.
Figure 4: The Quezon City smoker. Graphics by Danielle Quililan, Erricka Calvelo
What’s the outlook for lifetime smokers?
About eight out of 10 – or 84.3 percent, to be exact – ended up as regular smokers.
Most of them – or 81.6 percent – saying that they had been smoking for a long time. This
suggests that smoking for them isn’t just a phase but a vice that could last a lifetime. In
fact, on the average, smokers in Quezon City have been smoking for 16 years.

Their habit comes with a price: Years of medical research have proven that smoking
directly causes many illnesses, many of them fatal. According to the WHO, four out of 10
Filipinos die every hour from smoking-related illnesses.

Financially, smoking can be a burden too.

There are more smokers in Quezon City – 79.6 percent – who buy per stick buyers than
those who buy per pack – or only 20.2 percent. And yet, the cost of cigarettes still makes
a big dent in a per-stick smoker’s budget.

On average, a smoker would spend around P209 weekly, or P836 monthly. If a smoker
belongs to a family that earns P6,000 monthly and the smoker spends P836 on
cigarettes alone, that’s 14 percent of the monthly family income gone up in smoke.

Most smokers may buy only per-stick. But they buy frequently, which is why they still end
up spending more. According to the study, a lot of smokers – or 72.8 percent – admitted
visiting sari-sari stores every day, and 66.7 percent of them would to buy two to 10
cigarette sticks. So, although a single stick only costs P3, the frequent purchases add
up.

Scaring smokers is not enough

Generally, graphic health warnings have proven to be effective.

Data from the study showed that the warnings played a big role in the changing the
smoking behavior of the respondents.

Around 42 percent of those who already changed their behavior said the warnings had a
great effect on their decision, while 28.7 percent said the warning somehow affected
their decision.

But despite these finding, graphic health warnings lag behind other media as a primary
source of information about smoking.

More could be done: Perhaps increasing the knowledge of smokers on smoking-related

diseases through other channels may be a better way to influence them to quit smoking.

The study results showed that television remained the top media that 73.1 percent of the
respondents relied on to learn about smoking-related diseases. This suggests that the
government could boost its anti-smoking campaign by using television as the main
medium in informing the public, especially smokers, about the hazards of smoking.

This might help provide the push for many smokers to start changing their smoking
behavior. Data showed that many are already starting to consider such actions.

In fact, among respondents who had not changed their smoking, 69.4 percent said they
intended to change their behavior in the near future. Of this number, 75.3 percent said
they could probably cut down on the number of sticks they smoke within a month.
This suggests that many smokers have already starting to think about the effects of their
habit on and that this could be an opportunity for the government to finally stop smoking
in the country once and for all.

In addition to informing them about the dangers of smoking, concerned agencies and
groups should start designing communication projects that will teach smokers how to
stop their smoking in order to increase their confidence in themselves that they can
change.

Asked if they can change their smoking behaviors, some of the informants said:

“Di ko mapigilan. Hinahanap ng lalamunan.” (“I can’t stop it. My throat craves for it.”)

“Mangyayari yun pag matanda na kami.” (“It may happen when we grow old.”)

“Pag matagal na, mahirap na tumigil.” (“When you’ve been doing it for long time, it’s hard
to stop.”)

Studies on behavior change suggest that it may not be enought to just scare smokers.
They should also be taught how to stop. Or else, they might just give up on the idea of
changing.

With an empirical study showing the initial impact of graphic health warnings, the path to
reduce cigarette consumption among Filipinos is on to a good start. The warnings have
started scaring smokers. It’s time to start educating them properly through other
channels. –ATM

***

[The study was conducted by UP Diliman Communication Research students Knulp

Aseo, Angelle Braganza, Erricka Calvelo, Myrnelle Cinco, Monique Danao, Jesse
Doctor, Shaira Montes, Danielle Quililan, Meghan Reyes, Dannica San Juan, Anj
Silvestre for CommRes 165 – Data Interpretation, Reporting, and Utilization class under
Dr. Elena Pernia.]

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