Text and graphic warnings on cigarette packages

http://www.who.int/bulletin/volumes/87/8/09-069575/en/
• An important health communication intervention
Theories in social and health psychology, supported by empirical studies, have demonstrated the superiority of using pictures and imagery over text-only messages in health communication. Since the 1950s, many research studies have demonstrated that “fear appeals” are effective in motivating health behavior change (e.g. quitting), especially if paired with information about how to avoid the fearful consequences (e.g. where to find help about quitting).
• Effectiveness of warnings
research studies that support the use of pictorial warnings, notably in the European Union. Taken as a whole, the research on pictorial warnings show that they are: more likely to be noticed than text-only warning labels; more effective for educating smokers about the health risks of smoking and for increasing smokers’ thoughts about the health risks; and associated with increased motivation to quit smoking.
A recent analysis of data from the ITC Four Country Survey compared the impact of the introduction of pictorial warnings in Australia in 2005 to that of the introduction of larger text-only warnings in the United Kingdom in 2003. Cognitive and behavioral indicators of label impact that are predictive of quit intentions and quit attempts (e.g. forgoing cigarettes because of the labels; thinking about the health risks of smoking) increased to a greater extent among smokers after the Australian pictorial warnings were introduced than they did in the United Kingdom after enhanced text-only warnings were introduced. Pictorial warnings are also cited by former smokers as an important factor in their attempt to quit and have been associated with increases in the use of effective cessation services, such as toll-free telephone “help lines”. Although all warnings are subject to wear-out over time, pictorial warnings have also been shown to sustain their effects longer than text-only warning labels.
Pictorial warnings were rated by all groups as being more effective than text-only warning labels for motivating smokers to quit.
• No adverse consequences
The tobacco industry has suggested that the use of large pictures may reduce the effectiveness of health warnings and could actually lead to increases in smoking behavior.
However, there is no evidence that pictorial warnings lead to boomerang effects. An analysis of data from the ITC Four Country Survey found that the Australian pictorial warnings, introduced in 2005, led to greater avoidant behaviors (e.g. covering up the pack, keeping it out of sight, or avoiding particular labels), compared to Canada, the United Kingdom, and the USA. Importantly, those smokers who engaged in avoidant behaviors were no less likely to intend to quit or to attempt to quit,8 replicating the findings of a study of the Canadian warnings. Thus, although pictorial warnings can lead to avoidance and defensive reactions, such reactions are actually indicators of positive impact.
• Smokers support warnings
Research shows that smokers want to see more health information on cigarette packages. Data from ITC surveys of smokers from 10 countries in 2006 shows that the percentage of smokers who want to see more information on cigarette packages is greater than the percentage of smokers who want to see less information – even in countries where pictorial warning labels had already been introduced.

• Graphic pictures can significantly enhance the effectiveness of warning labels. In many countries, the warning label is the only sustained population-level mechanism by which governments inform their people about the harms of cigarettes and other tobacco products and, in those countries, the evidence-based inclusion of pictures could potentially lead to greater impact. For decades, the tobacco industry has taken advantage of the package as a venue for creating positive associations for their product. The use of graphic pictures is an important means of replacing those positive associations with negative associations, which is far more appropriate given the devastating impact of tobacco products on global health.
• Fong GT. The International Tobacco Control Policy Evaluation Project: Evaluating global tobacco policies of the Framework Convention on Tobacco Control [plenary presentation]. In: 8th Asia Pacific Conference on Tobacco or Health (APACT), Taipei, October 2007.
• Cunningham R. Cigarette package warning size and use of pictures: international summary. Ottawa: Canadian Cancer Society; 7 July 2009. Available from: http://www.tobaccolabels.ca/labelima/healthwarn [accessed on 13 July 2009].
• Fong GT. What we know and don’t (yet) know about the impact of tobacco control policies: an in-progress summary from the ITC Project. In: Invited public health and epidemiology plenary lecture, Society for Research on Nicotine and Tobacco, Dublin, Ireland, April 2009.
• Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong HH, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control 2009. Published online.

United Kingdom

• The United Kingdom implemented their current health warnings policy to place pictorial health warnings on cigarette packages by October 2008 in 2007, as a result of the European Commission labeling directive. Including the border, health warnings will be required to 43% of the front and 53% of the back of all cigarette packages. Overall, 48% of the pack space is appropriated to health warnings. The United Kingdom will rotate a set of 15 images.
http://www.tobaccolabels.ca/wp01/wp01-content/uploads/2013/12/Canada-2011-Canadians-Welcome-New-Graphic-Warnings-on-Cigarette-Packages-Cdn-Public-Opinion-Poll.pdf

Canadian Public Opinion Poll

• Canadians Welcome New Graphic Warnings on Cigarette Packages
– A majority of Canadians (60%) believe the images are about right, while one-in-four (24%) would have preferred more graphic imagery, and only 12 per cent think the images are too graphic.
– 82% support having health warnings on tobacco products.
– 60% think the new more graphic images that will be featured in cigarette packages are “about right.
– 48% think the images will be effective in convincing smokers to quit.
http://www.tobaccolabels.ca/wp01/wp01-content/uploads/2013/12/Australia-2011-Smokers-recall-of-Australian-graphic-cigarette-packet-warnings-and-awareness-of-associated-health-effects-BMC-Pub-Health-Miller.pdf

Smokers’ recall of Australian graphic cigarette packet warnings & awareness of associated health effects, 2005-2008.
– This study also examines the varying impact of different warnings, to see whether warnings with visceral images have greater impact on smokers’ beliefs than other images.
– l graphic pack warnings have had the intended impact on smokers. Some have greater impact than others. The implications for policy makers in countries introducing similar warnings are that fresh messaging and visceral images have the greatest impact.
– Cigarette packet warnings are an important form of health communication to consumers. Australia’s graphic health warnings were designed to provide “a strong and confronting message to smokers about the harmful health consequences of tobacco products and convey the ‘quit’ message every time a person reaches for a cigarette”.
– Theories of consumer behavior and social psychology predict that a number of predisposing variables influence behavior and the probability of behavioral change, with people’s beliefs being an important contributor [4-7]. Consumer behavior theory holds that behavior change, such as stopping smoking, can be induced by increasing consumer perception that the behavior is a ‘problem’ for them, requiring behavioral modification . By increasing a person’s belief that smoking leads to negative health consequences, pack warnings could change the consumer’s satisfaction with his/her current status as a smoker and induce (or increase) his/her desire to quit, increasing the chances that sh/he would try to quit.
http://www.tobaccolabels.ca/wp01/wp01-content/uploads/2013/12/India-2011-Are-current-tobacco-pictorial-warnings-in-India-effective-Asian-Pacific-J-Cancer-Prev-Oswal-et-al.pdf

Are Current Tobacco Pictorial Warnings in India Effective?
– Methodology: To understand people’s attitude towards the pictorial warning and their understanding of the pictures, a study was planned in two phases. The first phase was qualitative with focus group discussion and second, a population based survey for validating the findings. Results: The findings of the study suggested that the mandated pictorial warnings do not serve the desired purpose since they are not properly understood.
– The results of both the focus group discussions and the field survey indicate that most people have seen text and pictorial warnings on smokeless and smoking tobacco products, but that they lack relevance to the text messages. Irrespective of education the early proposed pictorial warnings by the government were more effective than the currently implemented warnings.

http://www.tobaccolabels.ca/wp01/wp01-content/uploads/2013/12/USA-2010-Understanding-how-graphic-pictorial-warnings-work-on-cigarette-packaging-J-Pub-Policy-Mktg-Kees-et-al.pdf

Understanding How Graphic Pictorial Warnings Work on Cigarette Packaging

– Many of the pictorial cigarette warnings use graphic visuals that may evoke fear related to the consequences of smoking (Physicians for a Smoke-Free Canada 2010). Although some researchers argue that gruesome pictorial warnings on packages denigrate and shame adult consumers, which may reduce warning effectiveness (Wilson et al. 2009), public health messages have long used negative-consequence themes in the form of fear appeals to generate attention and motivate action in attempts to persuade users to change destructive behaviors.
– more graphic pictures are predicted to have favorable effects on intentions to quit smoking through the level of fear evoked, highly graphic pictures may have a negative impact on copy test variables, such as message recall and package attitude. We expect that smokers will have less favorable evaluations of cigarette packages that contain graphic pictures reminding them of the health consequences of smoking than packages that contain less graphic warnings.
– predicts that increasing the graphic depiction of the pictorial warnings will result in stronger intentions to quit smoking. indicate that the pictorial warning manipulation had a significant, positive effect on smokers’ intentions to quit smoking.

http://www.tobaccolabels.ca/wp01/wp01-content/uploads/2013/12/UK-2010-Evaluating-the-impact-of-picture-health-warnings-on-cigarette-packets-Evaluation-Report-Wardle-et-al.pdf

Evaluating the impact of Picture Health Warnings on Cigarette Packets

– Support for and awareness of the picture health warnings was high. Almost all people in England believe that the warnings are necessary, impart important information and are credible. The impact of the picture health warnings so far, has been modest, at least in changing behaviour. Among adults, there was agreement that the pictures made smoking seem less attractive and that the pictures put people off smoking. Smokers were more likely to report that the warnings messages made them think about their smoking behaviour and thought about quitting smoking after the pictures warnings were introduced.
Impact of picture health warnings
– the impact of the picture health warnings was much more modest among young people than adults. In part, this is to be expected. Smoking prevalence is lower among young people aged 13-17 than adults and therefore this age group has lower exposure to the messages, particularly the back of packet messages.
– The Smoking, Drinking and Drug Use Survey (SDD) has demonstrated that 61% of young people aged 11-15 source their cigarettes by being given them from other people. Furthermore, in October 2007, the legal age to purchase cigarettes was increased from 16 to 18 making it more difficult for young people to buy cigarette packets.

Text and graphic warnings on cigarette packages

http://www.who.int/bulletin/volumes/87/8/09-069575/en/
• An important health communication intervention
Theories in social and health psychology, supported by empirical studies, have demonstrated the superiority of using pictures and imagery over text-only messages in health communication. Since the 1950s, many research studies have demonstrated that “fear appeals” are effective in motivating health behavior change (e.g. quitting), especially if paired with information about how to avoid the fearful consequences (e.g. where to find help about quitting).
• Effectiveness of warnings
research studies that support the use of pictorial warnings, notably in the European Union. Taken as a whole, the research on pictorial warnings show that they are: more likely to be noticed than text-only warning labels; more effective for educating smokers about the health risks of smoking and for increasing smokers’ thoughts about the health risks; and associated with increased motivation to quit smoking.
A recent analysis of data from the ITC Four Country Survey compared the impact of the introduction of pictorial warnings in Australia in 2005 to that of the introduction of larger text-only warnings in the United Kingdom in 2003. Cognitive and behavioral indicators of label impact that are predictive of quit intentions and quit attempts (e.g. forgoing cigarettes because of the labels; thinking about the health risks of smoking) increased to a greater extent among smokers after the Australian pictorial warnings were introduced than they did in the United Kingdom after enhanced text-only warnings were introduced. Pictorial warnings are also cited by former smokers as an important factor in their attempt to quit and have been associated with increases in the use of effective cessation services, such as toll-free telephone “help lines”. Although all warnings are subject to wear-out over time, pictorial warnings have also been shown to sustain their effects longer than text-only warning labels.
Pictorial warnings were rated by all groups as being more effective than text-only warning labels for motivating smokers to quit.
• No adverse consequences
The tobacco industry has suggested that the use of large pictures may reduce the effectiveness of health warnings and could actually lead to increases in smoking behavior.
However, there is no evidence that pictorial warnings lead to boomerang effects. An analysis of data from the ITC Four Country Survey found that the Australian pictorial warnings, introduced in 2005, led to greater avoidant behaviors (e.g. covering up the pack, keeping it out of sight, or avoiding particular labels), compared to Canada, the United Kingdom, and the USA. Importantly, those smokers who engaged in avoidant behaviors were no less likely to intend to quit or to attempt to quit,8 replicating the findings of a study of the Canadian warnings. Thus, although pictorial warnings can lead to avoidance and defensive reactions, such reactions are actually indicators of positive impact.
• Smokers support warnings
Research shows that smokers want to see more health information on cigarette packages. Data from ITC surveys of smokers from 10 countries in 2006 shows that the percentage of smokers who want to see more information on cigarette packages is greater than the percentage of smokers who want to see less information – even in countries where pictorial warning labels had already been introduced.

• Graphic pictures can significantly enhance the effectiveness of warning labels. In many countries, the warning label is the only sustained population-level mechanism by which governments inform their people about the harms of cigarettes and other tobacco products and, in those countries, the evidence-based inclusion of pictures could potentially lead to greater impact. For decades, the tobacco industry has taken advantage of the package as a venue for creating positive associations for their product. The use of graphic pictures is an important means of replacing those positive associations with negative associations, which is far more appropriate given the devastating impact of tobacco products on global health.
• Fong GT. The International Tobacco Control Policy Evaluation Project: Evaluating global tobacco policies of the Framework Convention on Tobacco Control [plenary presentation]. In: 8th Asia Pacific Conference on Tobacco or Health (APACT), Taipei, October 2007.
• Cunningham R. Cigarette package warning size and use of pictures: international summary. Ottawa: Canadian Cancer Society; 7 July 2009. Available from: http://www.tobaccolabels.ca/labelima/healthwarn [accessed on 13 July 2009].
• Fong GT. What we know and don’t (yet) know about the impact of tobacco control policies: an in-progress summary from the ITC Project. In: Invited public health and epidemiology plenary lecture, Society for Research on Nicotine and Tobacco, Dublin, Ireland, April 2009.
• Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong HH, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control 2009. Published online.

United Kingdom

• The United Kingdom implemented their current health warnings policy to place pictorial health warnings on cigarette packages by October 2008 in 2007, as a result of the European Commission labeling directive. Including the border, health warnings will be required to 43% of the front and 53% of the back of all cigarette packages. Overall, 48% of the pack space is appropriated to health warnings. The United Kingdom will rotate a set of 15 images.
http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/Canada-2011-Canadians-Welcome-New-Graphic-Warnings-on-Cigarette-Packages-Cdn-Public-Opinion-Poll.pdf

Canadian Public Opinion Poll

• Canadians Welcome New Graphic Warnings on Cigarette Packages
– A majority of Canadians (60%) believe the images are about right, while one-in-four (24%) would have preferred more graphic imagery, and only 12 per cent think the images are too graphic.
– 82% support having health warnings on tobacco products.
– 60% think the new more graphic images that will be featured in cigarette packages are “about right.
– 48% think the images will be effective in convincing smokers to quit.
http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/Australia-2011-Smokers-recall-of-Australian-graphic-cigarette-packet-warnings-and-awareness-of-associated-health-effects-BMC-Pub-Health-Miller.pdf

Smokers’ recall of Australian graphic cigarette packet warnings & awareness of associated health effects, 2005-2008.
– This study also examines the varying impact of different warnings, to see whether warnings with visceral images have greater impact on smokers’ beliefs than other images.
– l graphic pack warnings have had the intended impact on smokers. Some have greater impact than others. The implications for policy makers in countries introducing similar warnings are that fresh messaging and visceral images have the greatest impact.
– Cigarette packet warnings are an important form of health communication to consumers. Australia’s graphic health warnings were designed to provide “a strong and confronting message to smokers about the harmful health consequences of tobacco products and convey the ‘quit’ message every time a person reaches for a cigarette”.
– Theories of consumer behavior and social psychology predict that a number of predisposing variables influence behavior and the probability of behavioral change, with people’s beliefs being an important contributor [4-7]. Consumer behavior theory holds that behavior change, such as stopping smoking, can be induced by increasing consumer perception that the behavior is a ‘problem’ for them, requiring behavioral modification . By increasing a person’s belief that smoking leads to negative health consequences, pack warnings could change the consumer’s satisfaction with his/her current status as a smoker and induce (or increase) his/her desire to quit, increasing the chances that sh/he would try to quit.
http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/India-2011-Are-current-tobacco-pictorial-warnings-in-India-effective-Asian-Pacific-J-Cancer-Prev-Oswal-et-al.pdf

Are Current Tobacco Pictorial Warnings in India Effective?
– Methodology: To understand people’s attitude towards the pictorial warning and their understanding of the pictures, a study was planned in two phases. The first phase was qualitative with focus group discussion and second, a population based survey for validating the findings. Results: The findings of the study suggested that the mandated pictorial warnings do not serve the desired purpose since they are not properly understood.
– The results of both the focus group discussions and the field survey indicate that most people have seen text and pictorial warnings on smokeless and smoking tobacco products, but that they lack relevance to the text messages. Irrespective of education the early proposed pictorial warnings by the government were more effective than the currently implemented warnings.

http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/USA-2010-Understanding-how-graphic-pictorial-warnings-work-on-cigarette-packaging-J-Pub-Policy-Mktg-Kees-et-al.pdf

Understanding How Graphic Pictorial Warnings Work on Cigarette Packaging

– Many of the pictorial cigarette warnings use graphic visuals that may evoke fear related to the consequences of smoking (Physicians for a Smoke-Free Canada 2010). Although some researchers argue that gruesome pictorial warnings on packages denigrate and shame adult consumers, which may reduce warning effectiveness (Wilson et al. 2009), public health messages have long used negative-consequence themes in the form of fear appeals to generate attention and motivate action in attempts to persuade users to change destructive behaviors.
– more graphic pictures are predicted to have favorable effects on intentions to quit smoking through the level of fear evoked, highly graphic pictures may have a negative impact on copy test variables, such as message recall and package attitude. We expect that smokers will have less favorable evaluations of cigarette packages that contain graphic pictures reminding them of the health consequences of smoking than packages that contain less graphic warnings.
– predicts that increasing the graphic depiction of the pictorial warnings will result in stronger intentions to quit smoking. indicate that the pictorial warning manipulation had a significant, positive effect on smokers’ intentions to quit smoking.

http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/UK-2010-Evaluating-the-impact-of-picture-health-warnings-on-cigarette-packets-Evaluation-Report-Wardle-et-al.pdf

Evaluating the impact of Picture Health Warnings on Cigarette Packets

– Support for and awareness of the picture health warnings was high. Almost all people in England believe that the warnings are necessary, impart important information and are credible. The impact of the picture health warnings so far, has been modest, at least in changing behaviour. Among adults, there was agreement that the pictures made smoking seem less attractive and that the pictures put people off smoking. Smokers were more likely to report that the warnings messages made them think about their smoking behaviour and thought about quitting smoking after the pictures warnings were introduced.
Impact of picture health warnings
– the impact of the picture health warnings was much more modest among young people than adults. In part, this is to be expected. Smoking prevalence is lower among young people aged 13-17 than adults and therefore this age group has lower exposure to the messages, particularly the back of packet messages.
– The Smoking, Drinking and Drug Use Survey (SDD) has demonstrated that 61% of young people aged 11-15 source their cigarettes by being given them from other people. Furthermore, in October 2007, the legal age to purchase cigarettes was increased from 16 to 18 making it more difficult for young people to buy cigarette packets.