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Text and Graphic Warnings on Cigarette Packages
Open accessAbstract
Background Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the United States. The current study examined the effectiveness of health warnings on cigarette packages in four countries.Methods Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (n=14,975): Canada (n=3687), United States (n=4273), UK (n=3634), and Australia (n=3381). Surveys were conducted between 2002 and 2005, before and at three time points following implementation of new package warnings in the UK.Results At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave.Conclusions Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.
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“Quasi-experimental evidence supports these findings.133,143”
From Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association (2012) · cites this paper as [133]
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“These studies demonstrate that warning labels are most effective in countering the attractiveness and persuasiveness of cigarettes when they are visually noticeable,132,133 avoid the use of chemical names or ingredients,134 are specific rather than general,135 include pictorial and especially graphic136 warnings, are attributed to a specific source (eg, “medical studies,” “the Ministry of Health”)”
From Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association (2012) · cites this paper as [133]
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“For permissions, please e-mail: journals.permissions@oup.com. doi:10.1093/ntr/ntt124 Original investigatiOn affective and Cognitive Mediators of the impact of Cigarette Warning labels Lydia F. Emery BA1, Daniel Romer PhD1, Kaitlin M. Sheerin BA1, Kathleen Hall Jamieson PhD1, Ellen Peters PhD2 1Annenberg Public Policy…”
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“Methods: Adult smokers (n = 404) in four states participated in experimental auctions.”
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Self-citationVisual attention to health warnings on plain tobacco packaging in adolescent smokers and non‐smokers
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“(7) Departamento de Sociología, Universidad de la República.”
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“Several published studies, mostly conducted in high income countries, have confirmed the superiority of graphic pack warnings compared to text-based warnings in informing the public about the risks of smoking and stimulating interesting in quitting smoking [6,8-12].”
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Meernik, C., Jarman, K. L., Wright, S. T., Klein, E. G., Goldstein, A. O., & Ranney, L. M. (2016) · Tobacco Regulatory Science · doi:10.18001/trs.2.4.9 · Cited by 73
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“Only fewstudies compare the effects of a combination of pictorial and written warnings by for example comparing their effects in different countries or for various survey years [20–23].”
BackgroundInfluentialNeural correlates of cigarette health warning avoidance among smokers
Stothart, G., Maynard, O., Lavis, R., & Munafo, M. R. (2016) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2016.01.025 · Cited by 70
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“Compared to traditional mass media channels such as TV or radio, cigarette warning labels are at a lower cost and have an “unparalleled reach among smokers” (Hammond et al., 2007, p. 202), which makes warning labels an appealing tool for spreading anti-smoking messages.”
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“Furthermore, cross-country comparisons of longitudinal data suggest that the impact of graphic warnings on smokers is more sustainable over time than text-only messages, which appear to “wear out” more quickly as smokers habituate to them (Hammond et al., 2007).”
BackgroundInfluentialCorrecting Over 50 Years of Tobacco Industry Misinformation
Smith, P. M. R., Bansal‐Travers, M., O’Connor, R. J., Brown, A., Banthin, C. N., Guardino-Colket, S., & Cummings, K. M. (2011) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2011.01.020 · Cited by 64
Self-citationThrasher, J. F., Swayampakala, K., Cummings, K. M., Hammond, D. G., Anshari, D., Krugman, D. Μ., & Hardin, J. W. (2016) · Preventive Medicine · doi:10.1016/j.ypmed.2016.03.006 · Cited by 64
“While other studies also have found evidence of “wear out” (Borland et al., 2009b; Hammond et al., 2007), this is the first to evince “wear in,” signifying the importance of future research in this area.”
ResultSelf-citationQuitting smoking in China: findings from the ITC China Survey
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“…survey (i.e., September 2012) indicated a relatively high percentage of smokers who talked about HWLs (50%), with a decrease over subsequent waves, as found for cognitive responses to pictorial HWLs over longer periods of time (Hitchman et al., 2014; Borland et al., 2009b; Hammond et al., 2007).”
BackgroundSelf-citationThrasher, J. F., Murukutla, N., Pérez-Hernández, R., Alday, J., Arillo‐Santillán, E., Cedillo, C., & Gutiérrez, J. P. (2012) · Tobacco Control · doi:10.1136/tobaccocontrol-2011-050282 · Cited by 61
Flavoured cigarettes, sensation seeking and adolescents’ perceptions of cigarette brands
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Adolescents' Attention to Traditional and Graphic Tobacco Warning Labels: An Eye-Tracking Approach
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“, “Smoking when pregnant harms your baby”) now cover 30% of the front and 40% of the back of cigarette packs (Hammond et al., 2007).”
BackgroundHiilamo, H., & Glantz, S. A. (2015) · Social Science & Medicine · doi:10.1016/j.socscimed.2014.11.054 · Cited by 58
“, 2007), especially in countries with low illiteracy or where several languages are spoken (Hammond et al., 2007).”
Muñoz, Y., Chebat, J., & Suissa, A. J. (2010) · Journal of Gambling Studies · doi:10.1007/s10899-010-9182-4 · Cited by 58
“For the anti-smoking campaigns, researchers have revealed that warnings with fear appeals and strong images are working quit well (Hammond et al., 2007), but little research has been devoted to explore their use and potential benefits on the gambling behavior field.”
BackgroundTobacco control policy in the UK: blueprint for the rest of Europe?
Levy, D. T., Currie, L. M., & Clancy, L. (2012) · European Journal of Public Health · doi:10.1093/eurpub/cks090 · Cited by 58
Moodie, C. S., MacKintosh, A. M., & Hammond, D. G. (2009) · European Journal of Public Health · doi:10.1093/eurpub/ckp199 · Cited by 61
Self-citationHammond, D. G., Reid, J. L., Driezen, P., Cummings, K. M., Borland, R., Fong, G. T., & McNeill, A. D. (2008) · Addiction · doi:10.1111/j.1360-0443.2008.02320.x · Cited by 57
Self-citationAppeal to fear in health care: appropriate or inappropriate?
Simpson, J. (2017) · Chiropractic & Manual Therapies · doi:10.1186/s12998-017-0157-8 · Cited by 64
A glossary of culture in epidemiology
Hruschka, D. J., & Hadley, C. (2008) · Journal of Epidemiology & Community Health · doi:10.1136/jech.2008.076729 · Cited by 56
Social Interactions Sparked by Pictorial Warnings on Cigarette Packs
Hall, M., Peebles, K., Bach, L., Noar, S. M., Ribisl, K. M., & Brewer, N. T. (2015) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph121013195 · Cited by 57
“Previous studies have found that cigarette pack warnings are most effective when newly implemented and that responses to the warnings tend to partially “wear out” over the course of months or years [31–34].”
BackgroundEffect of message congruency on attention and recall in pictorial health warning labels
Lochbuehler, K., Mercincavage, M., Tang, K. Z., Tomlin, C. D., Cappella, J. N., & Strasser, A. A. (2017) · Tobacco Control · doi:10.1136/tobaccocontrol-2016-053615 · Cited by 54
“However, because a goal of PWLs is to inform smokers about the health risks associated with tobacco, 34 35 examining the effects on memory performance is important.”
BackgroundSmith, K. C., Washington, C., Brown, J. L., Vadnais, A., Kroart, L., Ferguson, J. M., & Cohen, J. E. (2015) · JMIR Public Health and Surveillance · doi:10.2196/publichealth.4616 · Cited by 53
“Exposure to health warnings that are larger, placed on the front upper face of the tobacco package, and that contain pictures, are more effective than smaller text-only warnings [5,8,17,18].”
Salloum, R. G., Maziak, W., Hammond, D. G., Nakkash, R. T., Islam, F., Cheng, X., & Thrasher, J. F. (2015) · BMJ Open · doi:10.1136/bmjopen-2015-009497 · Cited by 53
“A price proxy was included in our choice sets in order to estimate willingness to pay, a monetary measure of value typically used in determining the relative ranking of attributes and the trade-offs across attributes.”
MethodSelf-citationEvans, A. T., Peters, E. M., Shoben, A. B., Meilleur, L. R., Klein, E. G., Tompkins, M. K., Römer, D., & Tusler, M. (2016) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntw389 · Cited by 53
Purmehdi, M., Legoux, R., Carrillat, F., & Senecal, S. (2017) · Journal of Public Policy & Marketing · doi:10.1509/jppm.14.047 · Cited by 55
Swayampakala, K., Thrasher, J. F., Yong, H., Nagelhout, G. E., Li, L., Borland, R., Hammond, D. G., O’Connor, R. J., & Hardin, J. W. (2017) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntx134 · Cited by 51
Self-citationWomen's Perspectives on Smoking and Pregnancy and Graphic Warning Labels
Levis, D. M., Stone-Wiggins, B., O’Hegarty, M., Tong, V. T., Polen, K. N. D., & Cassell, C. H. (2014) · American Journal of Health Behavior · doi:10.5993/ajhb.38.5.13 · Cited by 49
Risk perceptions and food-handling practices in the home
Evans, K. S., Teisl, M. F., Lando, A. M., & Liu, S. T. (2020) · Food Policy · doi:10.1016/j.foodpol.2020.101939 · Cited by 50
Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation
Levy, D. T., Mays, D. M., Yuan, Z., Hammond, D. G., & Thrasher, J. F. (2016) · Tobacco Control · doi:10.1136/tobaccocontrol-2016-053087 · Cited by 49
Self-citationGraphic Health Warnings on Cigarette Packs: How Long Before the Effects on Adolescents Wear Out?
WHITE, V. M., Bariola, E., Faulkner, A., Coomber, K., & Wakefield, M. A. (2014) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntu184 · Cited by 49
Counteracting Media's Thin-Body Ideal for Adolescent Girls: Informing Is More Effective Than Warning
Veldhuis, J., Konijn, E. A., & Seidell, J. C. (2014) · Media Psychology · doi:10.1080/15213269.2013.788327 · Cited by 48
“, 2009) and were rated effective by smokers (Hammond et al., 2007).”
BackgroundLee, H., Lin, H., Seo, D., & Lohrmann, D. K. (2017) · Addictive Behaviors · doi:10.1016/j.addbeh.2017.07.033 · Cited by 48
Woelbert, E., & d’Hombres, B. (2019) · Tobacco Control · doi:10.1136/tobaccocontrol-2018-054402 · Cited by 48
Methods of the International Tobacco Control (ITC) China Survey
Wu, C., Thompson, M. E., Fong, G. T., Li, Q., Jiang, Y., Yang, Y., & Feng, G. (2009) · Tobacco Control · doi:10.1136/tc.2009.029900 · Cited by 48
Self-citationTobacco Industry Marketing, Population-Based Tobacco Control, and Smoking Behavior
Pierce, J. P. (2007) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2007.09.007 · Cited by 45
Front-of-pack labels: “Directive” versus “informative” approaches
Donini, L. M., Berry, E. M., Folkvord, F., Jansen, L., Leroy, F., Şimşek, Ö., Fava, F., Gobbetti, M., & Lenzi, A. (2022) · Nutrition · doi:10.1016/j.nut.2022.111861 · Cited by 43
Hammond, D. G. (2011) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntr182 · Cited by 45
Self-citationTobacco as a Substance of Abuse
Sims, T. H. (2009) · PEDIATRICS · doi:10.1542/peds.2009-2121 · Cited by 44
Graphic warning labels and the demand for cigarettes
Starr, M., & Drake, K. M. (2016) · Tobacco Control · doi:10.1136/tobaccocontrol-2015-052775 · Cited by 41
[Towards informed tobacco consumption in Mexico: effect of pictorial warning labels in smokers].
Thrasher, J. F., Pérez-Hernández, R., Arillo‐Santillán, E., & Barrientos‐Gutiérrez, I. (2012) · PubMed · Cited by 41
Reactions to graphic health warnings in the United States
Nonnemaker, J. M., Choinière, C. J., Farrelly, M. C., Kamyab, K., & Davis, K. (2014) · Health Education Research · doi:10.1093/her/cyu036 · Cited by 41
Graphic Gambling Warnings: How they Affect Emotions, Cognitive Responses and Attitude Change
Muñoz, Y., Chebat, J., & Borges, A. A., Jr. (2012) · Journal of Gambling Studies · doi:10.1007/s10899-012-9319-8 · Cited by 40
Awareness and impact of New York City's graphic point-of-sale tobacco health warning signs
Coady, M. H., Chan, C. A., Auer, K., Farley, S. M., Kilgore, E. A., & Kansagra, S. M. (2012) · Tobacco Control · doi:10.1136/tobaccocontrol-2011-050261 · Cited by 40
“While changing smokers’ purchasing behaviours and preventing relapse is clearly more challenging, a large body of scientific evidence has demonstrated that graphic cigarette pack warnings can increase quit smoking success and decrease youth smoking initiation.(14) 27 While pack warnings influence smoking attitudes and…”
BackgroundResultInfluentialErku, D., Bauld, L., Dawkins, L., GARTNER, C. E., Steadman, K. J., Noar, S. M., Shrestha, S., & Morphett, K. (2021) · Addiction · doi:10.1111/add.15473 · Cited by 42
Metadata
- Authors
- Hammond, D., Fong, G. T., Borland, R., Cummings, K. M., McNeill, A., & Driezen, P.
- Affiliations
- University of Waterloo (CA)
- Cancer Council Victoria (AU)
- Roswell Park Comprehensive Cancer Center (US)
- University of Nottingham (GB)
- Corresponding author
- Hammond, David
- Venue
- American Journal of Preventive Medicine
- Publisher
- Elsevier BV
- Published
- 2007-03
- Volume
- 32
- Issue
- 3
- Pages
- 202-209
- ISSN
- 0749-3797 (ISSN-L)
- PMC
- PMC1868456
- OpenAlex
- W2152630311
- Cited by
- 434
- References
- 22
- Citations by year
- 2026: 1 · 2025: 12 · 2024: 9 · 2023: 8 · 2022: 14 · 2021: 15 · 2020: 19 · 2019: 48 · 2018: 33 · 2017: 31 · 2016: 30 · 2015: 32 · 2014: 26 · 2013: 24 · 2012: 34
- FWCI
- 16.92
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Preventive Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Cancer Institute (P50CA111236, R01CA100362)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Public Health Policies and Epidemiology
- Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
- Keywords
- graphic health warnings, warning effectiveness, cross-national comparison, tobacco control, United States, United Kingdom, Canada, Australia
- MeSH terms
- Smoking Prevention, Adult, Australia, Canada, Consumer Product Safety, Female, United Kingdom, Health Promotion, Humans, International Cooperation, Health Knowledge, Attitudes, Practice, Male, Middle Aged, Product Labeling, Smoking, United States
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