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The World Health Organization's Framework Convention on Tobacco Control recommends prominent pictorial health warnings on tobacco products. To advance research methods, theory and understanding of how tobacco product warning labels (TPWLs) work, the US National Cancer Institute convened a grantee meeting. Our article describes the key insights that emerged from the meeting, situated within the context of the scientific literature. First, presentations confirmed that large, pictorial TPWLs motivate people to try to quit and encourage smoking cessation. Second, pictorial TPWLs increase attention, knowledge, negative affect, and thinking about the warning. Third, TPWL studies have primarily used brief-exposure laboratory studies and observational studies of sustained exposure through national policy implementation, with a few randomized trials involving several weeks of exposure-with generally consistent results found across study designs. Fourth, novel assessment methods include brain imaging, eye tracking and \"best-worst\" discrete choice experiments. To make TPWL even more effective, research is needed to confirm the mechanisms of their influence, their impact across vulnerable populations, and their effect on social media posts about tobacco products. Research is also needed on the effect of trial design choices, the predictive validity of new measurement approaches, and warning labels for non-cigarette tobacco products. To improve scientific understanding of TPWL effects, this grantee meeting summary describes emerging research methods, theory and study results. Directions for future research include examination of the mechanisms of how warning labels work across diverse tobacco products and across different populations and contexts.

More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images. Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, \"lived experience,\" symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses. Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, \"graphic\" health effects were rated as more effective than warnings depicting \"lived experience\" (p < .001) or \"symbolic\" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent. The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions. Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, \"lived experience,\" personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, \"graphic\" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be \"globally effective\" themes and styles for designing effective health warnings.

Abstract Introduction The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use. Methods We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual–verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes. Results Participants reported images that were graphic or “gross” would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions. Conclusions We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products. Implications This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults’ visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.

The cigarette, like the cigarette pack, is used by tobacco companies as a promotional tool. We explore how the cigarette could potentially be used as a dissuasive tool. An online survey was conducted with 15-30-year-old smokers and nonsmokers (N = 998) in France to explore their perceptions of a plain cigarette (gray with no brand name) and three branded cigarettes (regular, slim, pink). Participants were randomly assigned to view the plain cigarette and either the regular, slim, or pink cigarette. They were asked to rate the cigarettes by Appeal (tastiest, highest quality, and most expensive), Harm (most dangerous and most effective for motivating people to talk about tobacco dangers), and Perceived behavioral impact (most effective to convince teenagers not to start and to motivate smokers to reduce consumption and quit). In comparison to the gray cigarette, each of the branded cigarettes were considered more appealing, less harmful, and more likely to motivate teenagers to start and less likely to motivate smokers to reduce consumption or quit. The study suggests that altering the appearance of the cigarette may reduce cigarette appeal, increase harm perceptions, and deter both young people and smokers. Very little research has focused on dissuasive cigarettes whereas the cigarette stick has become very important for tobacco companies for communication purposes. This is the first study to compare the effect of various branded cigarettes (regular, slim, and pink) with a plain gray cigarette on young adult smokers and nonsmokers. The findings suggest that a plain gray cigarette can reduce cigarette appeal, increase perceptions of harm, and may deter use among both smokers and nonsmokers.

Research on electronic cigarette (e-cigarette) warnings has primarily focused on addiction warnings, such as the one soon to be required by the Food and Drug Administration (FDA) in the United States. However, reduced-risk warnings, similar to the warnings recently proposed for smokeless tobacco products, remain a future possibility for e-cigarettes. Thus, this brief report compares e-cigarette health risk perceptions based on reduced-risk warnings and the FDA addiction risk warning, and considers whether these warnings differ in believability, ease of comprehension, and perceptions about the clarity of risk communication. A quota sample of 672 smokers, e-cigarette users, dual users, and nonusers participated in this between-subjects experiment. Study participants were randomly assigned to one of three warning conditions, including the FDA-mandated addiction warning and two reduced-risk warnings. After exposure to the warning statement, participants responded to measures of health risk perceptions, believability, ease of comprehension, and perception about the clarity of risk communication. Results reveal that the addiction warning is perceived as more believable, easier to comprehend, and more clearly communicating the health risks of e-cigarettes use compared with the reduced-risk warnings. In addition, overall health risk perceptions and addiction risk perceptions based on the addiction warning are greater than health risk perceptions based on the reduced-risk warnings. In contrast, specific disease-related risk perceptions such as cancer, heart disease, lung disease, and harm to an unborn baby are greater for the reduced-risk warnings. This study provides a comparison of the forthcoming FDA-mandated e-cigarette addiction warning and reduced-risk warnings that have begun to be considered in the literature on a number of critical outcomes. This research provides a greater understanding of how variations of e-cigarette warnings, including addiction and reduced-risk warnings, are perceived by smokers, e-cigarette users, dual users, and nonusers. Specifically, findings show that overall health risk perceptions and addiction risk perceptions based on the addiction warning are greater than risk perceptions based on the reduced-risk warnings. In contrast, specific disease-related risk perceptions, such as cancer and heart disease, are greater for the reduced-risk warnings.

BackgroundThe US Food and Drug Administration (FDA) requires a warning label on nicotine e-cigarettes and pouches: ‘This product contains nicotine. Nicotine is an addictive chemical’. Some brands marketing synthetic nicotine products have modified the warning (‘This product contains tobacco-free nicotine (TFN)…’). The public health impact of altering the warning is unknown, so we examined its impact on risk perceptions and use intentions.Methods1000 participants completed an anonymous online survey. Participants viewed the black-and-white FDA and TFN-modified warning labels in isolation, in a randomised order and reported on perceived addictiveness and, secondarily, use intentions. Participants then selected which label conveyed the most harm overall. Generalised estimating equations (GEEs) were used to evaluate the impact of label type and participant characteristics on perceived addictiveness and, secondarily, use intentions. Multivariable logistic regression was used to evaluate relationships between participant characteristics and choosing which label conveyed the most harm.ResultsOverall, the TFN-modified label was associated with lower addictiveness ratings but not increased use intentions. Where significant interactions between label type and participant characteristics emerged, TFN-modified labelling was associated with disproportionately reduced risk perceptions or increased use intentions among vulnerable populations (eg, underage individuals, racially minoritised groups). 25.5% of participants selected the TFN-modified label as conveying the most harm, with younger individuals (<21 years) significantly less likely to choose the TFN-modified label.ConclusionsModifying the FDA-mandated nicotine warning label to include ‘tobacco-free nicotine’ may negatively impact public health, so the FDA should enforce inclusion of its original required warning label.

Recent research has shown that message congruency is beneficial to recall of pictorial health warning label (PWL) content after initial exposure. Despite less attention to the text warning, smokers exposed to congruent PWLs were more likely to recall the text and the message. This study aimed to replicate these findings and to examine whether congruency also affects recall after multiple exposures over time. A total of 320 daily smokers (39.7% female; cigarettes/day: M = 15.31, SD = 7.15) were randomized to one congruent or incongruent PWL and attended 4 laboratory sessions over 10 days. During each session, eye movements were recorded while viewing the PWL and open-ended recall of label content was assessed after exposure. Smokers who were exposed to a congruent PWL were more likely to recall the text (p = .01) and the message (p = .02) and less likely to recall the image (p = .003) of the PWL after initial exposure. By day 4, incongruent PWLs were recalled equally well as congruent PWLs. Independent of condition, image recall was initially high and remained high whereas text and message recall was relatively low initially but increased over time. It was not until day 7 that about 80% of text and message recall was observed. Even when exposed to the same PWL over time, smokers require multiple exposures to recall the text and the message of a PWL. More research on the effects of congruency in the natural environment, where smokers are exposed to multiple PWLs, is needed. The findings of this study, and of previous work showing that message congruency in PWLs is beneficial to initial recall of PWL content, could potentially help to address legal challenges regarding the implementation of PWLs in the United States. Factually correct text warnings have been uncontested on US cigarettes packages since 1966. Congruent PWLs simply provide a means to visually support the same information as the existing text using a medium that better garners attention to the health information. Investigating and understanding longer-term effects of congruency are important and can empirically inform future warning label development, both in the United States via the Family Smoking Prevention and Tobacco Control Act, and via other governing bodies.

Abstract Introduction Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. Methods A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. Results Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05). Conclusions Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact. Implications Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

BackgroundFlavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents.MethodsWe conducted an experimental survey. Participants aged 13–34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression.Results1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, ‘Tropical Burst’ named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, ‘Arctic Air’ named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001).ConclusionsColours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

Abstract Introduction Under the US Family Smoking Prevention and Tobacco Control Act, the US Food and Drug Administration (FDA) has the authority to implement graphic warning labels (GWLs) on cigarette packages. Neither the original labels proposed by the FDA nor the revised labels include a source to indicate sponsorship of the warnings. This study tests the potential impact of adding a sponsor to the content of GWLs. Methods We recruited adult smokers (N = 245) and middle-school youth (N = 242) from low-income areas in the Northeastern US. We randomly assigned participants to view one of three versions of the original FDA–proposed warning labels in a between-subjects experiment: no sponsor, “US Food and Drug Administration,” or “American Cancer Society” sponsor. We tested the effect of varying sponsorship on source attribution and source credibility. Results Compared to unsponsored labels, FDA sponsorship increased source attributions that the FDA sponsored the labels among both middle-school, largely nonsmoking youth and adult smokers. However, sponsorship had no effect on source credibility among either population. Conclusions We found no evidence that adding FDA as the source is likely to boost source credibility judgments, at least in the short term; though doing so would not appear to have adverse effects on credibility judgments. As such, our data are largely consistent with the Tobacco Control Act’s provisions that allow, but do not require, FDA sponsorship on the labels. Implications This study addresses the FDA’s regulatory efforts by informing the possible design and content of future cigarette warning labels. Our results do not offer compelling evidence that adding the FDA name on GWLs will directly increase source credibility. Future work may test more explicit FDA source labeling and continue to examine the credibility of tobacco message content among high–priority populations.