Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey
Open accessAbstract
Background:Health warnings on cigarette packages are among the most common means of communicating the health risks of smoking. However, few studies have evaluated the impact of package warnings on consumer knowledge about tobacco risks. Objective:The aim of the current study was to use nationally representative samples of adult smokers from the United States (USA), the United Kingdom (UK), Canada (CAN), and Australia (AUS) from the International Tobacco Control Four Country Survey (ITC-4) to examine variations in smokers’ knowledge about tobacco risks and the impact of package warnings. Methods:A telephone survey was conducted with 9058 adult smokers from the following countries: USA (n = 2138), UK (n = 2401), CAN (n = 2214) and AUS (n = 2305). Respondents were asked to state whether they believed smoking caused heart disease, stroke, impotence, lung cancer in smokers, and lung cancer in non-smokers. Respondents were also asked whether the following chemicals are found in cigarette smoke: cyanide, arsenic and carbon monoxide. Findings:Smokers in the four countries exhibited significant gaps in their knowledge of the risks of smoking. Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease. In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge. For example, in Canada, where package warnings include information about the risks of impotence, smokers were 2.68 (2.41–2.97) times more likely to agree that smoking causes impotence compared to smokers from the other three countries. Conclusion:Smokers are not fully informed about the risks of smoking. Warnings that are graphic, larger, and more comprehensive in content are more effective in communicating the health risks of smoking.
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Many countries, including Australia, Brazil, Canada, South Korea, and the USA, achieved sizeable declines in smoking prevalence well before FCTC adoption.
“many countries, including Australia, Brazil, Canada, South Korea, and the USA, among others, achieved sizeable declines in smoking prevalence well before FCTC adoption.15, 56, 57, 58”
From Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015 (2017) · cites this paper as [15]
The Results (page unavailable) compare smokers’ knowledge and intentions to quit across four countries, not changes in smoking prevalence. The Conclusion (page unavailable) discusses warning labels and the FCTC, but does not report pre-FCTC prevalence trends. Searches for declines in smoking prevalence and for Brazil and South Korea found no passage addressing the claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAn international survey including adult smokers from the United States, United Kingdom, Canada, and Australia demonstrated that smokers who notice the warnings were more likely to endorse health risks and that knowledge of health risks was greater in countries with more mandated government warnings.
“An international survey including adult smokers from the United States, United Kingdom, Canada, and Australia demonstrated that smokers who notice the warnings were more likely to endorse health risks and that knowledge of health risks was greater in countries with more mandated government warnings.140”
From Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association (2012) · cites this paper as [140]
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Cites
The theory of planned behavior
Ajzen, I. (1991) · Organizational Behavior and Human Decision Processes · doi:10.1016/0749-5978(91)90020-t · Cited by 90,587 · see citing works
Self-efficacy: Toward a unifying theory of behavioral change
Bandura, A. (1977) · Psychological Review · doi:10.1037/0033-295x.84.2.191 · Cited by 43,925 · see citing works
Self-efficacy: Toward a unifying theory of behavioral change
Bandura, A. (1978) · Advances in Behaviour Research and Therapy · doi:10.1016/0146-6402(78)90002-4 · Cited by 10,586 · see citing works
The Health Belief Model: a decade later.
Janz, N. K., & Becker, M. H. (1984) · Health Education Quarterly · doi:10.1177/109019818401100101 · Cited by 8,437 · see citing works
Murray, C. J. L., & López, A. D. (1997) · The Lancet · doi:10.1016/s0140-6736(96)07492-2 · Cited by 7,007 · see citing works
The Health Consequences of Smoking: A Report of the Surgeon General
Office on Smoking (2004) · Cited by 2,414 · see citing works
The health consequences of smoking. A report to the Surgeon General: 1971.
Welfare., E. (1971) · Cited by 1,195 · see citing works
Predictors of cessation in a cohort of current and former smokers followed over 13 years
Hyland, A. J., Li, Q., Bauer, J. E., Giovino, G. A., Steger, C., & Cummings, K. M. (2004) · Nicotine & Tobacco Research · doi:10.1080/14622200412331320761 · Cited by 394 · see citing works
Self-citationScollo, M., Lal, A., Hyland, A. J., & Glantz, S. A. (2003) · Tobacco Control · doi:10.1136/tc.12.1.13 · Cited by 369 · see citing works
Experiments with Incentives in Telephone Surveys
Singer, E., Hoewyk, J. V., & Maher, M. P. (2000) · Public Opinion Quarterly · doi:10.1086/317761 · Cited by 365 · see citing works
Impact of the graphic Canadian warning labels on adult smoking behaviour
Hammond, D. G., Fong, G. T., McDonald, P., Cameron, R., & Brown, K. S. (2003) · Tobacco Control · doi:10.1136/tc.12.4.391 · Cited by 358 · see citing works
Self-citationGraphic Canadian cigarette warning labels and adverse outcomes: evidence from Canadian smokers
Hammond, D., Fong, G. T., McDonald, P. W., Brown, K. S., & Cameron, R. (2004) · American Journal of Public Health · doi:10.2105/ajph.94.8.1442 · Cited by 331 · see citing works
Self-citationAccuracy of smokers' risk perceptions
Weinstein, N. D. (1998) · Annals of Behavioral Medicine · doi:10.1007/bf02884459 · Cited by 319 · see citing works
Perceived Risks of Heart Disease and Cancer Among Cigarette Smokers
Ayanian, J. Z. (1999) · JAMA · doi:10.1001/jama.281.11.1019 · Cited by 235 · see citing works
Curry, S. J., Grothaus, L. C., & McBride, C. M. (1997) · Addictive Behaviors · doi:10.1016/s0306-4603(97)00059-2 · Cited by 229 · see citing works
Are smokers adequately informed about the health risks of smoking and medicinal nicotine?
Cummings, K. M., Hyland, A. J., Giovino, G. A., Hastrup, J. L., Bauer, J. E., & Bansal, M. (2004) · Nicotine & Tobacco Research · doi:10.1080/14622200412331320734 · Cited by 211 · see citing works
Self-citationBest practices for comprehensive tobacco control programs, August 1999
Pechacek, T. F., Starr, G. B., Judd, B. T., Selin, H., Fishman, J., Albuquerque, M. S., Niemeyer, D. R., McKenna, J. W., Husten, C. G., Murphy, P. E., et al. (1999) · Cited by 182 · see citing works
Smoking: Risk, Perception, and Policy
Travis, C. C. (2002) · Risk Analysis · doi:10.1111/0272-4332.t01-1-00015 · Cited by 179 · see citing works
Smokers' beliefs about “Light” and “Ultra Light” cigarettes
Shiffman, S. M., Pillitteri, J. L., Burton, S. L., Rohay, J. M., & Gitchell, J. G. (2001) · Tobacco Control · doi:10.1136/tc.10.suppl_1.i17 · Cited by 179 · see citing works
Do cigarette smokers have unrealistic perceptions of their heart attack, cancer, and stroke risks?
Strecher, V. J., Kreuter, M. W., & Kobrin, S. C. (1995) · Journal of Behavioral Medicine · doi:10.1007/bf01857704 · Cited by 165 · see citing works
Perceptions of immunity to disease in adult smokers
Lee, C. (1989) · Journal of Behavioral Medicine · doi:10.1007/bf00844871 · Cited by 150 · see citing works
Schoenbaum, M. (1997) · American Journal of Public Health · doi:10.2105/ajph.87.5.755 · Cited by 150 · see citing works
Perceptions of smoking risk as a function of smoking status
McCoy, S. B., Gibbons, F. X., Reis, T. J., Gerrard, M., Lüüs, C. A. E., & Sufka, A. V. W. (1992) · Journal of Behavioral Medicine · doi:10.1007/bf00844942 · Cited by 141 · see citing works
Tobacco health warnings and smoking-related cognitions and behaviours
Borland, R. (1997) · Addiction · doi:10.1111/j.1360-0443.1997.tb02864.x · Cited by 126 · see citing works
Self-citationInitial impact of the new Australian tobacco health warnings on knowledge and beliefs
Borland, R., & Hill, D. (1997) · Tobacco Control · doi:10.1136/tc.6.4.317 · Cited by 116 · see citing works
Self-citationBorland, R., Yong, H., King, B., et al. (2004) · Nicotine & Tobacco Research · doi:10.1080/1462220412331320716 · Cited by 110 · see citing works
Self-citationAccuracy of smokers' risk perceptions
Weinstein, N. D. (1999) · Nicotine & Tobacco Research · doi:10.1080/14622299050011721 · Cited by 109 · see citing works
The Role of Perceived Risk in Starting and Stopping Smoking
Römer, D., & Jamieson, P. E. (2001) · Sage eBooks · doi:10.4135/9781452232652.n4 · Cited by 105 · see citing works
Binson, D., Canchola, J. A., & Catania, J. A. (2000) · Journal of Official Statistics · Cited by 98 · see citing works
Chapman, S. F., & Carter, S. M. (2003) · Tobacco Control · doi:10.1136/tc.12.suppl_3.iii13 · Cited by 96 · see citing works
Cummings, K. M., Morley, C. P., & Hyland, A. J. (2002) · Tobacco Control · doi:10.1136/tc.11.suppl_1.i110 · Cited by 81 · see citing works
Self-citationPublic understanding of the illnesses caused by cigarette smoking
Weinstein, N. D., Slovic, P., Waters, E. A., et al. (2004) · Nicotine & Tobacco Research · doi:10.1080/14622200410001676459 · Cited by 78 · see citing works
The Impact of Cigarette Warning Labels and Smoke-free Bylaws on Smoking Cessation
Hammond, D. G., McDonald, P., Fong, G. T., Brown, K. S., & Cameron, R. (2004) · Canadian Journal of Public Health · doi:10.1007/bf03403649 · Cited by 63 · see citing works
Self-citationWhat do Marlboro Lights smokers know about low-tar cigarettes?
Cummings, K. M., Hyland, A. J., Bansal, M., et al. (2004) · Nicotine & Tobacco Research · doi:10.1080/14622200412331320725 · Cited by 49 · see citing works
Self-citationNourjah, P. A., Wagener, D. K., Eberhardt, M. S., & Horowitz, A. M. (1994) · Journal of Public Health Policy · doi:10.2307/3343026 · Cited by 42 · see citing works
It's Time for a Change: Cigarette Smokers Deserve Meaningful Information About Their Cigarettes
Wilkenfeld, J. P., Henningfield, J. E., SLADE, J. D., Burns, D., & Pinney, J. M. (2000) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/92.2.90 · Cited by 42 · see citing works
Andersson, P., & Leppert, J. (2001) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1177/174182670100800606 · Cited by 38 · see citing works
Perceptions of lung cancer and smoking in an ecomomically disadvantaged population
Price, J. H., & Everett, S. A. (1994) · Journal of Community Health · doi:10.1007/bf02260405 · Cited by 36 · see citing works
International cigarette labelling practices
Aftab, M., Kolben, D., & Lurie, P. G. (1999) · Tobacco Control · doi:10.1136/tc.8.4.368 · Cited by 35 · see citing works
Few smokers know their cigarettes have filter vents.
Kozlowski, L. T., White, E. L., Sweeney, C. T., et al. (1998) · American Journal of Public Health · doi:10.2105/ajph.88.4.681-a · Cited by 17 · see citing works
Davis, R. M. (1998) · Tobacco Control · doi:10.1136/tc.7.3.227 · Cited by 12 · see citing works
Frank, E., Denniston, M. M., & Pederson, L. L. (2002) · PubMed · Cited by 8 · see citing works
Declines in Smokersʼ Understanding of Tobaccoʼs Hazards Between 1986 and 1998
Frank, E., DENNISTON, M., & PEDERSON, L. (2002) · Southern Medical Journal · doi:10.1097/00007611-200207000-00005 · Cited by 6 · see citing works
Pesticides and other chemicals in cigarette tobacco
Stockwell, T. R., Rutley, R., & Clark, K. (1992) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.1992.tb121624.x · Cited by 5 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Reitsma, M. B., Fullman, N., Ng, M., Salama, J. S., Abajobir, A., Abate, K. H., Abbafati, C., Abera, S. F., Abraham, B., Abyu, G. Y., et al. (2017) · The Lancet · doi:10.1016/s0140-6736(17)30819-x · Cited by 2,028 · see citing works
Health warning messages on tobacco products: a review
Hammond, D. (2011) · Tobacco Control · doi:10.1136/tc.2010.037630 · Cited by 1,162 · see citing works
Self-citationPictorial cigarette pack warnings: a meta-analysis of experimental studies
Noar, S. M., Hall, M. G., Francis, D. B., Ribisl, K. M., Pepper, J. K., & Brewer, N. T. (2016) · Tobacco Control · doi:10.1136/tobaccocontrol-2014-051978 · Cited by 674 · see citing works
Mozaffarian, D., Afshin, A., Benowitz, N. L., Bittner, V., Daniels, S. R., Franch, H. A., Jacobs, D. R., Kraus, W. E., Kris-Etherton, P. M., Krummel, D. A., et al. (2012) · Circulation · doi:10.1161/cir.0b013e318260a20b · Cited by 601 · see citing works
Avoidable global cancer deaths and total deaths from smoking
Jha, P. (2009) · Nature Reviews Cancer · doi:10.1038/nrc2703 · Cited by 522 · see citing works
Text and Graphic Warnings on Cigarette Packages
Hammond, D., Fong, G. T., Borland, R., Cummings, K. M., McNeill, A., & Driezen, P. (2007) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2006.11.011 · Cited by 434 · see citing works
Self-citationBenefitting InfoVis with Visual Difficulties
Hullman, J., Adar, E., & Shah, P. (2011) · IEEE Transactions on Visualization and Computer Graphics · doi:10.1109/tvcg.2011.175 · Cited by 159 · see citing works
Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior
Monárrez-Espino, J., Liu, B., Greiner, F., Bremberg, S., & Galanti, R. (2014) · American Journal of Public Health · doi:10.2105/ajph.2014.302129 · Cited by 85 · see citing works
Schneider, S., Gadinger, M., & Fischer, A. (2012) · Patient Education and Counseling · doi:10.1016/j.pec.2011.03.005 · Cited by 71 · see citing works
- Authors
- Hammond, D., Fong, G. T., McNeill, A., Borland, R., & Cummings, K. M.
- Affiliations
- University of Waterloo (CA)
- University College London (GB)
- Cancer Council Victoria (AU)
- Roswell Park Comprehensive Cancer Center (US)
- Corresponding author
- Hammond, D
- Venue
- Tobacco Control
- Publisher
- BMJ
- Published
- 2006-06
- Volume
- 15
- Issue
- suppl 3
- Pages
- iii19-iii25
- ISSN
- 0964-4563 (ISSN-L)
- 1468-3318
- PMC
- PMC2593056
- OpenAlex
- W2127885482
- Cited by
- 567
- References
- 44
- Citations by year
- 2026: 6 · 2025: 16 · 2024: 15 · 2023: 14 · 2022: 20 · 2021: 30 · 2020: 23 · 2019: 28 · 2018: 40 · 2017: 41 · 2016: 49 · 2015: 43 · 2014: 45 · 2013: 43 · 2012: 28
- FWCI
- 14.58
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Tobacco Control (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Figshare (submittedVersion, cc-by)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Cancer Research UK (P50 CA111236, 014578, C312/A3726, 265903, R01 CA 100362, 57897, 045734)
- Canadian Institutes of Health Research (C312/A3726, R01 CA 100362, 014578, 265903, 045734, P50 CA111236, 57897)
- Medical Research Council
- National Health and Medical Research Council (014578, 045734, 57897, P50 CA111236, 265903, C312/A3726, R01 CA 100362)
- National Cancer Institute (C312/A3726, 045734, 57897, 265903, P50CA111236, R01CA100362, 014578)
- Topics
- Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
- Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
- Keywords
- cigarette warning labels, smokers, health risk communication, lung cancer, heart disease, erectile dysfunction, passive smoking, cross-national comparison
- MeSH terms
- Smoking Prevention, Adolescent, Adult, Aged, Female, Health Promotion, Humans, Health Knowledge, Attitudes, Practice, Male, Middle Aged, Product Labeling, Smoke, Smoking, Nicotiana, Smoking Cessation, Tobacco Industry
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