Cited by 435Smoking Behavior and CessationGlobal Public Health Policies and EpidemiologyBehavioral Health and Interventions

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Text and Graphic Warnings on Cigarette Packages

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Hammond, David, Fong, Geoffrey T., Borland, Ron, Cummings, K. Michael, McNeill, Ann, Driezen, Pete·2007·American Journal of Preventive Medicine

DOI 10.1016/j.amepre.2006.11.011PMC PMC1868456

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Abstract

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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“Borland et al. (2009) and Hammond et al. (2007) examined crossnational comparisons to assess the effects of distressing imagery presented on cigarette packaging, while Durkin et al. (2009) took advantage of smokers' differential exposure to differing styles of antismoking advertising to examine…”
Background
Positive and instructive anti-smoking messages speak to older smokers: a focus group study
Cataldo, J., Hunter, M. M., Petersen, A., & Sheon, N. (2015) · Tobacco Induced Diseases · doi:10.1186/s12971-015-0027-x · Cited by 21
“Efforts are ongoing to adopt the larger graphic warnings used in other countries that have been found to be effective with respect to perceptions of risk and cessation-related behaviors [17].”
Background
Lessons from New Zealand’s introduction of pictorial health warnings on tobacco packaging
Hoek, J. A., Wilson, N., Allen, M., Edwards, R., Thomson, G., & Li, J. (2010) · Bulletin of the World Health Organization · doi:10.2471/blt.10.076695 · Cited by 21
Evaluating the Emotional Impact of Warning Images on Young Adult Smokers and Susceptible Non-Smokers
Gendall, P. J., Hoek, J. A., & Gendall, K. (2018) · Journal of Health Communication · doi:10.1080/10810730.2018.1440332 · Cited by 21
“Although interventions have spanned the marketing spectrum, many governments have paid special attention to on-pack warnings, which potentially reach smokers each time they retrieve a cigarette and increase knowledge of smoking’s harms (Hammond et al., 2007; Mutti, Hammond, Reid, & Thrasher, 2013).”
Background
Text and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study
Tanoue, L. T. (2008) · Yearbook of Pulmonary Disease · doi:10.1016/s8756-3452(08)70602-9 · Cited by 21
Demand Reduction from Plain and Pictorial Cigarette Warning Labels: Evidence from Experimental Auctions
Rousu, M. C., & Thrasher, J. F. (2012) · Applied Economic Perspectives and Policy · doi:10.1093/aepp/pps049 · Cited by 20
Let your past define your future? How recalling successful financial experiences can increase beliefs of self‐efficacy in financial planning
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Associations of Proposed Relative-Risk Warning Labels for Snus With Perceptions and Behavioral Intentions Among Tobacco Users and Nonusers
Rodu, B., Plurphanswat, N., Hughes, J. R., & Fagerström, K. O. (2015) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntv168 · Cited by 20
Effects of Repeated Exposure to a Graphic Smoking Warning Image
Rooke, S. E., Malouff, J. M., & Copeland, J. (2012) · Current Psychology · doi:10.1007/s12144-012-9147-0 · Cited by 20
“warnings less effective than the graphic warning images used in Australia and Canada (Hammond et al. 2007).”
BackgroundInfluential
Perceptions and acceptability of pictorial health warning labels vs text only - a cross-sectional study in Lao PDR
Sychareun, V., Hansana, V., Phengsavanh, A., Chaleunvong, K., & Tomson, T. (2015) · BMC Public Health · doi:10.1186/s12889-015-2415-9 · Cited by 20
Australian Smokers’ and Nonsmokers’ Exposure to Antismoking Warnings in Day-to-Day Life: A Pilot Study
Schüz, N., & Ferguson, S. G. (2014) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntu253 · Cited by 20
Effects on smokers of exposure to graphic warning images
Malouff, J. M., Schutte, N. S., Rooke, S. E., & MacDonell, G. (2012) · The American Journal on Addictions · doi:10.1111/j.1521-0391.2012.00284.x · Cited by 19
The Impact of Australia's New Graphic Cigarette Packet Warnings on Smokers’ Beliefs and Attitudes
Miller, C. L., Hill, D. J., Quester, P. G., & Hiller, J. E. (2011) · Australasian Marketing Journal (AMJ) · doi:10.1016/j.ausmj.2011.05.004 · Cited by 19
“graphic health warnings vs high and low profile text-based warnings) across countries and time has demonstrated that the stronger the warnings the greater their cognitive impact on smokers and the greater the behavioural reactions (Hammond et al., 2007).”
Background
Warning labels on junk food: experimental evidence
Boncinelli, F., Gerini, F., Pagnotta, G., & Alfnes, F. (2016) · International Journal of Consumer Studies · doi:10.1111/ijcs.12312 · Cited by 19
Pilot study of inducing smoking cessation attempts by activating a sense of looming vulnerability
McDonald, D., O’Brien, J. L., Farr, E., & Haaga, D. A. F. (2010) · Addictive Behaviors · doi:10.1016/j.addbeh.2010.02.008 · Cited by 19
“These images have been found to increase salience for these consequences, contemplation of quitting, and quit attempts (Borland et al., 2009; Hammond et al., 2007; Hammond, Fong, McDonald, Cameron, & Brown, 2003).”
Background
The effects of tobacco-related health-warning images on intention to quit smoking among urban Chinese smokers
Wu, D., Yang, T., Cottrell, R. R., Zhou, H., Yang, X. Y., & Zhang, Y. (2014) · Health Education Journal · doi:10.1177/0017896914535377 · Cited by 19
“UK smokers were also more likely to report that new graphic warnings caused them to think more about quitting (Hammond et al., 2007).”
Background
Waterpipe tobacco package warning exposure’s impact on risk perceptions and use among young adults in the USA: a longitudinal analysis of the population assessment of tobacco and health study
King, J., Reboussin, B., Ross, J. C., & Sutfin, E. (2018) · Tobacco Control · doi:10.1136/tobaccocontrol-2018-054562 · Cited by 19
Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents
Carl, A., Taillie, L. S., Grummon, A. H., Lazard, A. J., Higgins, I. C. A., Sheldon, J. M., & Hall, M. G. (2021) · Appetite · doi:10.1016/j.appet.2021.105234 · Cited by 19
Graphic imagery is not sufficient for increased attention to cigarette warnings: the role of text captions
Brown, K. G., Reidy, J. G., Weighall, A., & Arden, M. A. (2012) · Addiction · doi:10.1111/add.12008 · Cited by 18
Graphic and Arousing? Emotional and Cognitive Reactions to Tobacco Graphic Health Warnings and Associated Quit-Related Outcomes Among Low SEP Population Groups
Bekalu, M. A., Ramanadhan, S., Bigman, C. A., Nagler, R. H., & Viswanath, K. (2018) · Health Communication · doi:10.1080/10410236.2018.1434733 · Cited by 18
“…that GHWs may help to reduce SEP-based disparities in health knowledge by providing low SEP smokers with regular access to health risk information (Cantrell et al., 2013; Hammond et al., 2007) given that lack of access to health information is a major dimension of communication inequalities.”
Background
Do health warnings on cigarette sticks dissuade smokers and non-smokers? A focus group and interview study of Australian university students
Drovandi, A. D., Teague, P.-A., Glass, B. D., & Malau‐Aduli, B. S. (2019) · Psychology Research and Behavior Management · doi:10.2147/prbm.s193754 · Cited by 18
“However, recent research has identified these warnings are subject to diminished effectiveness over time, due to repetition of viewing and a loss of shock value.(12,16) There are also issues with the vulnerable population of younger smokers not identifying with the fatal and debilitating diseases portrayed on cigarett…”
Background
Consumers' decision-making process when choosing potentially risky, frequently used chemical household products: The case of laundry detergents.
Buchmüller, K., Xu, C., Bearth, A., & Siegrist, M. (2022) · Environmental Research · doi:10.1016/j.envres.2022.112894 · Cited by 16
Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers
Mostafa, A., Mohammed, H. T., Hussein, R. S., Hussein, W. M., ElHabiby, M. M., Safwat, W., Labib, S., & Fotouh, A. A. (2018) · PLoS ONE · doi:10.1371/journal.pone.0208590 · Cited by 18
Cigarette pack warning labels in Russia: how graphic should they be?
Wade, B., Merrill, R. M., & Lindsay, G. B. (2010) · European Journal of Public Health · doi:10.1093/eurpub/ckq098 · Cited by 17
Older African American Homeless-Experienced Smokers’ Attitudes Toward Tobacco Control Policies—Results from the HOPE HOME Study
Vijayaraghavan, M., Olsen, P., Weeks, J., McKelvey, K., Ponath, C., & Kushel, M. (2017) · American Journal of Health Promotion · doi:10.1177/0890117117729928 · Cited by 17
Examination of Voluntary Compliance with New FDA Cigar Warning Label Requirements
Wackowski, O. A., Kurti, M. K., Schroth, K. R. J., & Delnevo, C. D. (2020) · Tobacco Regulatory Science · doi:10.18001/trs.6.6.1 · Cited by 17
Graphic-enhanced information improves perceived risks of cigar smoking
Strasser, A. A., Orom, H., Tang, K. Z., Dumont, R. L., Cappella, J. N., & Kozlowski, L. T. (2011) · Addictive Behaviors · doi:10.1016/j.addbeh.2011.03.005 · Cited by 17
“…smoking risks compared to text-onlymessages taken from the National Cancer Institute (NCI) website, (see Dollar et al., 2008) Research on graphic communications (Hammond et al., 2007) led us to hypothesize that participants viewing the graphic version would have a better understanding of the risks.”
Informing tobacco control policy in Jordan: assessing the effectiveness of pictorial warning labels on cigarette packs
Bader, R. K., Shihab, R. A., Al-Rimawi, D., & Hawari, F. I. (2017) · BMC Public Health · doi:10.1186/s12889-017-4642-8 · Cited by 17
“While motivation is critical for the actual quitting behavior, it is not enough; a smoker needs a sense of self-efficacy to trigger a quit attempt [7, 11, 20].”
Background
Optimizing messages and images for e-cigarette warnings
Lazard, A. J., Kalan, M. E., Nicolla, S., Hall, M., Ribisl, K., Sheldon, J. M., Whitesell, C., Queen, T. L., & Brewer, N. (2023) · Tobacco Control · doi:10.1136/tc-2022-057859 · Cited by 15
Perceptions of young Jordanian adults to proposed anti-tobacco pictorial warning labels
Hawari, F. I., Bader, R. K., Beano, H. M., Obeidat, N. A., Ayub, H. S., Habashneh, M. A., Shtaiwi, A. S., Shihab, R. A., Madanat, H. N., & Novotny, T. E. (2011) · BMC Public Health · doi:10.1186/1471-2458-11-414 · Cited by 19
Impact of cigarette package warnings on attitudes towards sharing and gifting cigarettes in China: a nationwide study of smokers and non-smokers
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Self-citation
Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon
Layoun, N., Salameh, P., Waked, M., Bacha, Z. A., Zeenny, R. M., Hitti, E. E., Godin, I., & Dramaix, M. W. (2017) · Patient Preference and Adherence · doi:10.2147/ppa.s122877 · Cited by 16
“Thus, textonly warnings have been rated by smokers as ineffective and unnoticeable.(12,13) On the contrary, pictorial warnings have been proven to be instrumental in reducing the burden of tobacco use.”
Background
Do prominent warnings make packaging less attractive?
Kovačević, D., Brozović, M., & Možina, K. (2018) · Safety Science · doi:10.1016/j.ssci.2018.08.031 · Cited by 16
The effectiveness of plain packaging in discouraging tobacco consumption in Australia
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Impact of Canadian tobacco packaging policy on quitline reach and reach equity
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Self-citation
Responsible gambling signage on electronic gaming machines, before and after the implementation of the United Kingdom Gambling Act: an observational study
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“Indeed, large warnings on cigarette packages have been found to be more likely to be noticed and rated as effective by smokers (Hammond et al., 2007; O’Hegarty, Pederson, Nelson, Wortley & Yenokyan, 2007).”
Cross-country comparison of smokers' reasons for thinking about quitting over time: findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002–2015
Kasza, K. A., Hyland, A. J., Borland, R., McNeill, A. D., Fong, G. T., Carpenter, M. J., Partos, T., & Cummings, K. M. (2016) · Tobacco Control · doi:10.1136/tobaccocontrol-2016-053299 · Cited by 15
Self-citation

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
ORCID: Hammond, David
Fong, Geoffrey T.
Borland, Ron
Cummings, K. Michael
McNeill, Ann
Driezen, Pete
Venue: American Journal of Preventive Medicine
Publisher: Elsevier BV
Published: 2007-03
Volume: 32
Issue: 3
Pages: 202-209
ISSN: 0749-3797 (ISSN-L)
DOI: 10.1016/j.amepre.2006.11.011
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
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
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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Text and Graphic Warnings on Cigarette Packages

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