Reactions to graphic health warnings in the United States

Abstract

This study reports consumer reactions to the graphic health warnings selected by the Food and Drug Administration to be placed on cigarette packs in the United States. We recruited three sets of respondents for an experimental study from a national opt-in e-mail list sample: (i) current smokers aged 25 or older, (ii) young adult smokers aged 18-24 and (iii) youth aged 13-17 who are current smokers or who may be susceptible to initiation of smoking. Participants were randomly assigned to be exposed to a pack of cigarettes with one of nine graphic health warnings or with a text-only warning statement. All three age groups had overall strong negative emotional (ß = 4.7, P < 0.001 for adults; ß = 4.6, P < 0.001 for young adults and ß = 4.0, P < 0.001 for youth) and cognitive (ß = 2.4, P < 0.001 for adults; ß = 3.0, P < 0.001 for young adults and ß = 4.6, P < 0.001 for youth) reactions to the proposed labels. The strong negative emotional and cognitive reactions following a single exposure to the graphic health warnings suggest that, with repeated exposures over time, graphic health warnings may influence smokers' beliefs, intentions and behaviors.

Assessing the Consequences of Implementing Graphic Warning Labels on Cigarette Packs for Tobacco-Related Health Disparities

“…Smokers may be less willing to endorse PE of GWLs for themselves than they are for other people. Additionally, Nonnemaker and colleagues' PE-like construct (cognitive impact) 10 includes GWL salience, which one would also expect to boost reported PE over TWLs. As for quit intentions, Cantrell and colleagues 18 found they were greater for GWLs among whites, African Americans, Hispanics, and smokers with some college education.…”

“…5,6 In general population samples, GWLs have been found to be more effective than TWLs. [6][7][8][9][10] GWLs in Canada significantly decreased smoking rates by 3-4 percentage points over 9 years relative to the United States. 8 GWLs have also increased knowledge about tobacco harms, discouraged nonsmokers from experimenting, prevented former smokers from relapsing, and increased smokers' intentions and attempts to quit, even discouraging them from having a cigarette when they were about to.…”

“…6,9 More specifically, the GWLs proposed by the US Food and Drug Administration (FDA) have produced strong negative emotional responses and perceptions of effectiveness among general population samples of US smokers. 7,10 However, not enough is known about the effects of GWLs on tobacco-related health disparities. 6,11,12 A recent meta-analysis found that cigarette price increases most consistently reduce the gap between high and low socioeconomic groups, while marketing controls (including health warning labels) either reduce the gap or impact all groups equally.…”

“…We built on findings from previous studies that have tested the effectiveness of the FDAproposed GWLs, 7,10,18,20 by assessing the potential impact of each individual warning label as well as the set of GWLs. We compared responses from those exposed to GWLs and those exposed to TWLs on quit intentions, and on eight other measures shown to be positively associated with quitting intentions or behaviors: (1) "negative emotional responses," which may play a role in message acceptance and are positively linked to thinking about the health risks of smoking, quit intentions, and quit behaviors 6,23 ; (2) "perceived effectiveness of the warning" (PE), as PE ratings of smoking cessation public service announcements have been shown to predict quit intentions and subsequent changes in smoking behavior [24][25][26] ; (3) "beliefs about the harms of smoking," as having concerns about the effect of smoking on health has been shown to predict quit attempts 27 ; (4) "intentions to talk about the warning," as smokers who talk about GWLs are more likely to quit smoking or make cessation attempts 28 ; "intentions to talk about quitting" (with either (5) "a medical professional" or (6) "a close other") as that is also predictive of increased quit intentions and behaviors 29,30 ; (7) "intentions to avoid warnings"; and (8) "intentions to hold back from smoking a cigarette as a result of warnings," as avoiding warning labels and forgoing smoking a cigarette also increases the likelihood of quitting activities as well as decreasing adolescent intentions to smoke.…”

“…agree). Negative emotional responses were measured by averaging six emotions felt while looking at the warning (worry, guilt, disgust, sadness, regret, and anger at themselves for being smokers; Cronbach's α = .91; adapted from Nonnemaker and colleagues 10 ). PE was measured by the degree to which: the warning was "relevant to my everyday life," "important to me," "convincing," "believable," "accurate," "makes me think about what it would be like if the situation shown in the warning happened to me," "put thoughts in my mind about quitting," and "put thoughts in my mind about wanting to continue smoking."…”