Cited by 674Smoking Behavior and CessationBehavioral Health and InterventionsGlobal Public Health Policies and Epidemiology

The DOI matches its Crossref record; 101 of the 102 references it cites were found in a registry or an index; none of the 71 sources its claims cite is checked for support yet.

Pictorial cigarette pack warnings: a meta-analysis of experimental studies

Open access

Abstract

OBJECTIVE: To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. DATA SOURCES: We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. STUDY SELECTION: We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33,613) met criteria. DATA EXTRACTION AND SYNTHESIS: Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. RESULTS: Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. CONCLUSIONS: The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This meta-analysis of experimental studies found that pictorial cigarette pack warnings were generally more effective than text-only warnings across attention, reactions, attitudes, intentions, and perceived effectiveness. The authors conclude the evidence supports pictorial warnings but note major gaps in behavioural outcomes and theory-based research.

Key findings

  • Across 37 studies with 48 independent samples (N=33,613), pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes, with 13 of 17 outcomes showing statistically significant effects (most p<0.001).
  • Pictorial warnings improved attention attracting (d=0.79) and attention duration (d=1.74), cognitive elaboration (d=1.70), negative affective reactions (d=0.54), negative pack/brand attitudes (d=0.79), negative smoking attitudes (d=0.55), intention to not start smoking (d=1.82), and intention to quit smoking (d=0.54).
  • Pictorial warnings were rated as more effective than text warnings on all 8 perceived effectiveness outcomes, including motivating not starting smoking (d=1.03), motivating oneself to quit (d=0.79), motivating others to quit (d=1.09), and deterring giving cigarettes as a gift (d=1.64).
  • No significant effects were found for response time, recall/recognition of warning text, perceived likelihood of harm, or self-efficacy to quit; pictorial warnings also elicited greater psychological reactance (d=−0.50).

Methods

  • Systematic search of 7 computerised databases in April 2013 plus reference lists; inclusion required an experimental protocol testing cigarette pack warnings and reporting both pictorial and text-only conditions.
  • The final synthesis included 37 studies reporting 48 independent samples (N=33,613); two independent coders coded study characteristics with mean 96% agreement and mean Cohen’s κ=0.94.
  • Effect sizes used standardised mean difference d, combined with random-effects meta-analytic procedures; heterogeneity assessed with Q and I², and moderator analyses conducted for a composite perceived-effectiveness motivation variable.

Limitations

  • The paper states a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects; only a single experimental study assessed behaviour.
  • The paper notes that no study placed warnings on smokers’ own cigarette packs, exposures were brief and often on a computer screen, and all but one study assessed participants only immediately after exposure.
  • The text makes evident high heterogeneity for many outcomes (6 of 9 heterogeneous outcomes had I²>90), and moderator analyses found within-subject designs produced larger effects than between-subject designs (d=1.37 vs d=0.51), suggesting design-related variability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/tobaccocontrol-2014-051978

Cites

101 of 102 references verified1 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1 PRISMA flow diagram showing the study screening process.
Figure 1 PRISMA flow diagram showing the study screening process.CC BY · PubMed Central
Figure 2 Message impact framework applied to research on cigarette pack warnings.
Figure 2 Message impact framework applied to research on cigarette pack warnings.CC BY · PubMed Central
Figure 3 Forest plot displaying effect sizes and 95% CIs for attention outcomes.
Figure 3 Forest plot displaying effect sizes and 95% CIs for attention outcomes.CC BY · PubMed Central
Figure 4 Forest plot displaying effect sizes and 95% CIs for warning reactions.
Figure 4 Forest plot displaying effect sizes and 95% CIs for warning reactions.CC BY · PubMed Central
Figure 5 Forest plot displaying effect sizes and 95% CIs for attitudes/beliefs.
Figure 5 Forest plot displaying effect sizes and 95% CIs for attitudes/beliefs.CC BY · PubMed Central
Figure 6 Forest plot displaying effect sizes and 95% CIs for intentions.
Figure 6 Forest plot displaying effect sizes and 95% CIs for intentions.CC BY · PubMed Central
Figure 7 Forest plot displaying effect sizes and 95% CIs for perceived effectiveness.
Figure 7 Forest plot displaying effect sizes and 95% CIs for perceived effectiveness.CC BY · PubMed Central
Figure 8 Effects of pictorial warnings on cigarette packs (summary of findings).
Figure 8 Effects of pictorial warnings on cigarette packs (summary of findings).CC BY · PubMed Central

Verification

Claims the paper makes

65 Own result · 34 Not checked yet · 8 Own interpretation · 6 No basis given · 4 Own method

Verify all 71 references — free account
  • It may state two separate claims as one. 22
  • Probably not a substantial claim. 24
39 of 39
  • The paper relies on this without support.

    Perceived effectiveness ratings do not play a direct role in warning message effects.

    “However, currently, there is no evidence to suggest that these ratings play a direct role in warning message effects (ie, that participants must perceive a message to be effective in order for it to be so).”
  • The paper relies on this without support.

    The intermediate outcomes assessed in the experimental studies (attention, reactions, attitudes, and intentions) are valid indicators of warning effectiveness in changing smoking behaviour.

    “Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05).”
    “Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.”
2 of 2

Citations

Cites

Show all 101 references

Research works printed but not linked: 7

  1. Canadian Cancer Society, 2014, Cigarette package health warnings: international status report
  2. Nonnemaker, 2010, Experimental study of graphic cigarette warning labels: final results report
  3. National Cancer Institute, 2009, Cigarette warning labels, packaging & product labeling: current science & practice to identify research priorities
  4. McGuire, 1989, Theoretical foundations of campaigns, 43
  5. International Agency for Research on Cancer, 2008, Measures to assess the effectiveness of restrictions on tobacco product labeling policies
  6. McQueen, 2013, What are the reactions of diverse US smokers when graphic warning labels are affixed to their cigarette packs?
  7. Peters, 2014, Reactive and thoughtful processing of graphic warnings: multiple roles for affect

Cited by

Sorted by citations

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Metadata

Authors
Noar, S. M., Hall, M. G., Francis, D. B., Ribisl, K. M., Pepper, J. K., & Brewer, N. T.
Affiliations
University of North Carolina at Chapel Hill (US)
Corresponding author
Noar, Seth M
Venue
Tobacco Control
Publisher
BMJ
Published
2015-05-06
Volume
25
Issue
3
Pages
341-354
ISSN
  • 0964-4563 (ISSN-L)
  • 1468-3318
OpenAlex
W2126304455
Cited by
674
References
101
Citations by year
2026: 31 · 2025: 49 · 2024: 43 · 2023: 56 · 2022: 53 · 2021: 72 · 2020: 117 · 2019: 67 · 2018: 83 · 2017: 67 · 2016: 32 · 2015: 4
FWCI
7.58
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Tobacco Control (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • HighWire Press Open Archive (submittedVersion)
Funders
  • National Institutes of Health
  • Centers for Disease Control and Prevention (U48DP001944)
  • U.S. Public Health Service (P3OCAO1 6086-3832)
  • University of North Carolina at Chapel Hill
  • National Cancer Institute (P30CA016086)
  • Center for Tobacco Products
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
  • Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Public Health Policies and Epidemiology
Keywords
text-only warnings, tobacco warning labels, smoking prevention, smoking cessation intentions, attitudes toward smoking
MeSH terms
Smoking Prevention, Attention, Cognition, Health Education, Humans, Health Knowledge, Attitudes, Practice, Motivation, Photography, Product Labeling, Risk Factors, Smoking, Visual Perception, Health Behavior, Smoking Cessation, Risk Assessment, Tobacco Products

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