Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial | Lifestyle Behaviors | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.207.129.82. Please contact the publisher to request reinstatement.
1.
World Health Organization.  WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco. Geneva, Switzerland: World Health Organization; 2015.
2.
Stead  LF, Perera  R, Bullen  C,  et al.  Nicotine replacement therapy for smoking cessation.  Cochrane Database Syst Rev. 2012;11:CD000146.PubMedGoogle Scholar
3.
West  R, Zatonski  W, Cedzynska  M,  et al.  Placebo-controlled trial of cytisine for smoking cessation.  N Engl J Med. 2011;365(13):1193-1200.PubMedGoogle ScholarCrossref
4.
Volpp  KG, Troxel  AB, Pauly  MV,  et al.  A randomized, controlled trial of financial incentives for smoking cessation.  N Engl J Med. 2009;360(7):699-709.PubMedGoogle ScholarCrossref
5.
Zhu  S, Melcer  T, Sun  J, Rosbrook  B, Pierce  JP.  Smoking cessation with and without assistance: a population-based analysis.  Am J Prev Med. 2000;18(4):305-311.PubMedGoogle ScholarCrossref
6.
Frieden  TR.  A framework for public health action: the health impact pyramid.  Am J Public Health. 2010;100(4):590-595.PubMedGoogle ScholarCrossref
7.
World Health Organization.  WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2003.
8.
United States Public Laws. Federal Cigarette Labeling and Advertising Act of 1966. 89th Congress. Public Law 89-92.
9.
Institute of Medicine.  Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: Institute of Medicine; 2007.
10.
Canadian Cancer Society.  Cigarette Package Health Warnings: International Status Report. Ontario, Canada: Canadian Cancer Society; 2014.
11.
United States Public Laws. Family Smoking Prevention and Tobacco Control Act of 2009. 111th Congress, 1st Session. Public Law 111-31 [H.R. 1256]. 2009.
12.
R.J. Reynolds Tobacco Co vs United States Food and Drug Administration. Civil Case No. 11-1482 (RJL). United States District Court for the District of Columbia; 2011.
13.
Noar  SM, Hall  MG, Francis  D, Ribisl  KM, Pepper  J, Brewer  NT.  Pictorial cigarette pack warnings: a meta-analysis of experimental studies.  Tob Control. 2016;25(3):341-354.PubMedGoogle ScholarCrossref
14.
Noar  SM, Hall  MG, Brewer  NT.  Pictorial cigarette pack warnings have important effects.  Am J Public Health. 2015;105(3):e1.PubMedGoogle ScholarCrossref
15.
Hammond  D.  Health warning messages on tobacco products: a review.  Tob Control. 2011;20(5):327-337.PubMedGoogle ScholarCrossref
16.
Yong  HH, Borland  R, Thrasher  JF,  et al.  Mediational pathways of the impact of cigarette warning labels on quit attempts.  Health Psychol. 2014;33(11):1410-1420.PubMedGoogle ScholarCrossref
17.
Yong  HH, Fong  GT, Driezen  P,  et al.  Adult smokers’ reactions to pictorial health warning labels on cigarette packs in Thailand and moderating effects of type of cigarette smoked: findings from the international tobacco control southeast Asia survey.  Nicotine Tob Res. 2013;15(8):1339-1347.PubMedGoogle ScholarCrossref
18.
Azagba  S, Sharaf  MF.  The effect of graphic cigarette warning labels on smoking behavior: Evidence from the Canadian experience.  Nicotine Tob Res. 2013;15(3):708-717.PubMedGoogle ScholarCrossref
19.
Chang  FC, Sung  HY, Zhu  SH, Chiou  ST.  Impact of the 2009 Taiwan tobacco hazards prevention act on smoking cessation.  Addiction. 2014;109(1):140-146.PubMedGoogle ScholarCrossref
20.
Brewer  NT, Hall  MG, Lee  JG, Peebles  K, Noar  SM, Ribisl  KM.  Testing warning messages on smokers’ cigarette packages: a standardised protocol.  Tob Control. 2016;25(2):153-159.PubMedGoogle ScholarCrossref
21.
Hall  MG, Peebles  K, Bach  LE, Noar  SM, Ribisl  KM, Brewer  NT.  Social interactions sparked by pictorial warnings on cigarette packs.  Int J Environ Res Public Health. 2015;12(10):13195-13208.PubMedGoogle ScholarCrossref
22.
Nonnemaker  FM, Kamyab  K, Busey  A, Mann  N.  Experimental Study of Graphic Cigarette Warning Labels: Final Results Report. Research Triangle Park, NC: RTI International; 2010.
23.
Cameron  LD, Pepper  JK, Brewer  NT.  Responses of young adults to graphic warning labels for cigarette packages.  Tob Control. 2015;24(e1):e14-e22.PubMedGoogle ScholarCrossref
24.
Willis  GB.  Cognitive Interviewing: A Tool for Improving Questionnaire Design. Thousand Oaks, CA: Sage Publications, Inc; 2004.
25.
Brody  T.  Clinical Trials: Study Design, Endpoints and Biomarkers, Drug Safety, and FDA and ICH Guidelines. London, England: Academic Press; 2011.
26.
Gibson  L, Brennan  E, Momjian  A, Shapiro-Luft  D, Seitz  H, Cappella  JN.  Assessing the consequences of implementing graphic warning labels on cigarette packs for tobacco-related health disparities.  Nicotine Tob Res. 2015;17(8):898-907.PubMedGoogle ScholarCrossref
27.
Cantrell  J, Vallone  DM, Thrasher  JF,  et al.  Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment.  PLoS One. 2013;8(1):e52206.PubMedGoogle ScholarCrossref
28.
McAfee  T, Davis  KC, Alexander  RL  Jr, Pechacek  TF, Bunnell  R.  Effect of the first federally funded US antismoking national media campaign.  Lancet. 2013;382(9909):2003-2011.PubMedGoogle ScholarCrossref
29.
Centers for Disease Control and Prevention (CDC).  Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign—March 19–June 10, 2012.  MMWR Morb Mortal Wkly Rep. 2012;61(34):667-670.PubMedGoogle Scholar
30.
Brennan  E, Durkin  SJ, Cotter  T, Harper  T, Wakefield  MA.  Mass media campaigns designed to support new pictorial health warnings on cigarette packets: evidence of a complementary relationship.  Tob Control. 2011;20(6):412-418.PubMedGoogle ScholarCrossref
31.
Malouff  JM, Schutte  NS, Rooke  SE, MacDonell  G.  Effects on smokers of exposure to graphic warning images.  Am J Addict. 2012;21(6):555-557.PubMedGoogle ScholarCrossref
32.
McQueen  A, Kreuter  MW, Boyum  S,  et al.  Reactions to FDA-proposed graphic warning labels affixed to U.S. smokers’ cigarette packs.  Nicotine Tob Res. 2015;17(7):784-795.PubMedGoogle ScholarCrossref
33.
Wardle  H, Pickup  D, Lee  L,  et al.  Evaluating the Impact of Picture Health Warnings on Cigarette Packets. London, England: Public Health Research Consortium; 2010.
34.
Li  L, Borland  R, Yong  H,  et al.  Longer term impact of cigarette package warnings in Australia compared with the United Kingdom and Canada.  Health Educ Res. 2015;30(1):67-80.PubMedGoogle ScholarCrossref
35.
Borland  R, Wilson  N, Fong  GT,  et al.  Impact of graphic and text warnings on cigarette packs: findings from four countries over five years.  Tob Control. 2009;18(5):358-364.PubMedGoogle ScholarCrossref
36.
Shadish  WR, Cook  TD, Campbell  DT.  Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, MA: Cengage Learning; 2002.
37.
Witte  K.  Putting the fear back into fear appeals: The extended parallel process model.  Commun Monogr. 1992;59(4):329-349.Google ScholarCrossref
38.
Petty  RE, Cacioppo  JT.  The elaboration likelihood model of persuasion.  Adv Exp Soc Psychol. 1986;19:123-205.Google Scholar
39.
Hammond  D, Reid  JL, Driezen  P, Boudreau  C.  Pictorial health warnings on cigarette packs in the United States: an experimental evaluation of the proposed FDA warnings.  Nicotine Tob Res. 2013;15(1):93-102.PubMedGoogle ScholarCrossref
40.
Tannenbaum  MB, Hepler  J, Zimmerman  RS,  et al.  Appealing to fear: A meta-analysis of fear appeal effectiveness and theories.  Psychol Bull. 2015;141(6):1178-1204.PubMedGoogle ScholarCrossref
41.
Leventhal  H, Cleary  PD.  The smoking problem: a review of the research and theory in behavioral risk modification.  Psychol Bull. 1980;88(2):370-405.PubMedGoogle ScholarCrossref
42.
Thrasher  JF, Abad-Vivero  EN, Huang  L,  et al.  Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts  [published online May 31, 2015].  Soc Sci Med. 2015.PubMedGoogle Scholar
43.
Brewer  NT, Weinstein  ND, Cuite  CL, Herrington  JE.  Risk perceptions and their relation to risk behavior.  Ann Behav Med. 2004;27(2):125-130.PubMedGoogle ScholarCrossref
44.
Sheeran  P, Harris  PR, Epton  T.  Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies.  Psychol Bull. 2014;140(2):511-543.PubMedGoogle ScholarCrossref
45.
Nonnemaker  JM, Choiniere  CJ, Farrelly  MC, Kamyab  K, Davis  KC.  Reactions to graphic health warnings in the United States.  Health Educ Res. 2015;30(1):46-56.PubMedGoogle ScholarCrossref
46.
Romer  D, Peters  E, Strasser  AA, Langleben  D.  Desire versus efficacy in smokers’ paradoxical reactions to pictorial health warnings for cigarettes.  PLoS One. 2013;8(1):e54937.PubMedGoogle ScholarCrossref
47.
West  R, Hajek  P, Stead  L, Stapleton  J.  Outcome criteria in smoking cessation trials: proposal for a common standard.  Addiction. 2005;100(3):299-303.PubMedGoogle ScholarCrossref
48.
Tobacco Control Legal Consortium.  Cigarette Graphic Warnings and the Divided Federal Courts. St Paul, MN: Public Health Law Center; 2013.
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    3 Comments for this article
    EXPAND ALL
    Potential Effect of Economic Warnings
    Fatih TUFAN | Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine
    I congratulate the authors for their efforts in this invaluable field, smoking cessation. Demographic data of this trial indicate that more than half of the study participants had low income (<150% of federal poverty level). I wonder if pictorial warnings regarding problems associated with the economic burden of smoking could result in increased rates of smoking cessation attempts.
    CONFLICT OF INTEREST: None Reported
    Design on cigarette package in Norway
    Valerie Heemstra, D.O. | Innovative Health Systems, White Plains, NY 10603
    While visiting Norway in 2006, I saw a cigarette package on the ground with a design of a large skull and crossbones. The effect on me (a non-smoker) was shocking, and hopefully deterred at least some smokers. On the same trip, I noted chargers for electric cars on a street in Oslo. A Norwegian woman with breast cancer told me that she lives on Long Island in New York because care for breast cancer was better (in 2006) in the U.S., but encourages her daughter to continue to live in Norway, because all other healthcare in Norway was cheaper and just as good as in America, especially for young families. Thought-provoking anecdotes implying Norway may be a few steps ahead of the U.S. in some regards.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Respect the Rights of Disabled People
    Dr. Med. Andreas Schnitzler | Facharzt für Innere Medizin und Nephrologie
    It is completely irrelevant whether deterrent pictures of ill and disabled people are effective, because they violate the rights of disabled people in the sense of human dignity:

    "I consider the anti-smoking campaign by deterring images to be useful, but I object against providing smoking in direct relation to disability as a result of smoking. For example, there is a warning, smoking causes strokes and disability, accompanied by images of a pale, apathetic, in the wheelchair hanging woman or an artificially ventilated man in the hospital bed. These subjects provide a stereotyped and negative image of disability, which I
    regard as discriminatory“ (1). 

    The Austrian Deputy Dr. Huainigg is a ventilated wheelchair user.

    Subsequently, these images were taken back for Austria (2), and referred to the "European Disability Forum“.

    It must be seriously asked why these considerations were never taken into account.

    REFERENCES

    (1) https://www.bizeps.or.at/huainigg-behinderung-als-abschreckung-ist-nicht-akzeptabel/; accessed 19.07.2016

    (2) https://www.bizeps.or.at/schockbilder-auf-zigarettenpackungen-sollen-vom-rauchen-abhalten/; accessed 19.07.2016

    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    July 2016

    Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial

    Author Affiliations
    • 1Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
    • 2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
    • 3School of Media and Journalism, University of North Carolina, Chapel Hill
    • 4Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
    • 5Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
    JAMA Intern Med. 2016;176(7):905-912. doi:10.1001/jamainternmed.2016.2621
    Abstract

    Importance  Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain.

    Objective  To assess the effect of adding pictorial warnings to the front and back of cigarette packs.

    Design, Setting, and Participants  This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events.

    Interventions  We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General’s warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act’s required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs).

    Main Outcomes and Measures  The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General’s warning.

    Results  Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting.

    Conclusions and Relevance  Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking.

    Trial Registration  clinicaltrials.gov Identifier: NCT02247908

    ×