Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies
More details
Hide details
Department of Communication, University of Kentucky, Lexington, United States
Manship School of Mass Communication, Louisiana State University, Baton Rouge, United States
Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, United States
School of Media & Journalism, University of North Carolina at Chapel Hill, Chapel Hill, United States
Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, United States
Diane B. Francis   

Department of Communication, University of Kentucky, Lexington, Kentucky, 40506, United States
Publish date: 2019-05-15
Tob. Induc. Dis. 2019;17(May):41
We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

We systematically searched computerized databases and the reference list of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.

We would like to thank N. Brewer, K. Ribisl, and M. Hall for their contributions to earlier systematic reviews that provided a foundation for the current review study.
Authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
There was no source of funding for this research.
DBF, NM, JCR, and SMN conceptualized the study and reviewed all data collection instruments. DBF and NM coded and analyzed the data. DBF wrote the manuscript, and NM, JCR, and SMN contributed to revisions and reviewed the final draft of the manuscript.
Not commissioned; externally peer reviewed.
World Health Organization. WHO report on the global tobacco epidemic, 2017: Monitoring tobacco use and prevention policies. Geneva, Switzerland: World Health Organization; 2017. Accessed February 3, 2018.
World Health Organization. WHO global report: Mortality attributable to tobacco. Geneva, Switzerland: World Health Organization; 2012.
Arrazola RA, Ahluwalia IB, Pun E, Garcia de Quevedo I, Babb S, Armour BS. Current tobacco smoking and desire to quit smoking among students aged 13–15 years — global youth tobacco survey, 61 countries, 2012–2015. MMWR Morb Mortal Wkly Rep. 2017;66(20):533-537. doi:10.15585/mmwr.mm6620a3
US Department of Health and Human Services. The health consequences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 2014.
US Department of Health and Human Services. National survey on drug use and health, 2014. Ann Arbor: MI: Inter-University Consortium for Political and Social Research; 2014.
Monarrez-Espino J, Liu B, Greiner F, Bremberg S, Galanti R. Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior. Am J Public Health. 2014;104(10):e11-30. doi:10.2105/ajph.2014.302129
Noar SM, Francis DB, Bridges C, Sontag JM, Brewer NT, Ribisl KM. Effects of strengthening cigarette pack warnings on attention and message processing: A systematic review. Journal Mass Commun Q. 2016;94(2):416-442. doi:10.1177/1077699016674188
Noar SM, Francis DB, Bridges C, Sontag J, Ribisl K, Brewer N. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc Sci Med. 2016;164:118-129. doi:10.1016/j.socscimed.2016.06.011
Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob Control. 2015;25(3):341-354. doi:10.1136/tobaccocontrol-2014-051978
World Health Organization. Tobacco: Key facts. Published March 9, 2018. Accessed December 27, 2018.
Levy DT, Mays D, Yuan Z, Hammond D, Thrasher JF. Public health benefits from pictorial health warnings on US cigarette packs: A simsmoke simulation. Tob Control. 2017;26(6):649-655. doi:10.1136/tobaccocontrol-2016-053087
Abascal W, Esteves E, Goja B, Mora F, Lorenzo A, Sica A, et al. Tobacco control campaign in Uruguay: A population-based trend analysis. Lancet. 2012;380(9853):1575-1582. doi:10.1016/s0140-6736(12)60826-5
Harris JE, Balsa AI, Triunfo P. Tobacco control campaign in Uruguay: Impact on smoking cessation during pregnancy and birth weight. J Health Econ. 2015;42:186-196. doi:10.1016/j.jhealeco.2015.04.002
Miller CL, Hill DJ, Quester PG, Hiller JE. The impact of Australia’s new graphic cigarette packet warnings on smokers’ beliefs and attitudes. Australasian Marketing J. 2011;19(3):181-188. doi:10.1016/j.ausmj.2011.05.004
Miller CL, Quester PG, Hill DJ, Hiller JE. Smokers' recall of Australian graphic cigarette packet warnings & awareness of associated health effects, 2005-2008. BMC Public Health. 2011;11(1):238. doi:10.1186/1471-2458-11-238
Ross JC, Noar SM, Sutfin EL. Systematic review of health communication for non-cigarette tobacco products. Health Commun. 2019;34(3):361-369. doi:10.1080/10410236.2017.1407274
Francis DB, Hall MG, Noar SM, Ribisl KM, Brewer NT. Systematic review of measures used in pictorial cigarette pack warning experiments. Nicotine Tob Res. 2017;19(10):1127-1137. doi:10.1093/ntr/ntx082
Hammond D. Health warning messages on tobacco products: A review. Tob Control. 2011;20(5):327-337. doi:10.1136/tc.2010.037630
Hammond D. Tobacco packaging and labeling policies under the U.S. Tobacco control act: Research needs and priorities. Nicotine Tob Res. 2012;14(1):62-74. doi:10.1093/ntr/ntr182
Duffy SA, Burton D. Cartoon characters as tobacco warning labels. Arch Pediatr Adolesc Med. 2000;154(12):1230-1236. doi:10.1001/archpedi.154.12.1230
Adebiyi AO, Uchendu OC, Bamgboye E, Ibitoye O, Omotola B. Perceived effectiveness of graphic health warnings as a deterrent for smoking initiation among adolescents in selected schools in southwest Nigeria. Tob Induc Dis. 2016;14(March):1-7. doi:10.1186/s12971-016-0074-y
Hawari FI, Bader RK, Beano HM, Obeidat N, Ayub H, Habashneh M, et al. Perceptions of young Jordanian adults to proposed anti-tobacco pictorial warning labels. BMC Public Health. 2011;11(1):414. doi:10.1186/1471-2458-11-414
Goodall C, Appiah O. Adolescents' perceptions of Canadian cigarette package warning labels: Investigating the effects of message framing. Health Commun. 2008;23(2):117-127. doi:10.1080/10410230801967825
Baskerville NB, Hayward L, Brown KS, Hammond D, Kennedy RD, Campbell HS. Impact of Canadian tobacco packaging policy on quitline reach and reach equity. Prev Med. 2015;81:243-250. doi:10.1016/j.ypmed.2015.09.010
Adkison SE, Bansal-Travers M, Smith DM, O’Connor RJ, Hyland AJ. Impact of smokeless tobacco packaging on perceptions and beliefs among youth, young adults, and adults in the US: Findings from an internet-based cross-sectional survey. Harm Reduct J. 2014;11(2):2-11. doi:10.1186/1477-7517-11-2
Alaouie H, Afifi RA, Haddad P, Mahfoud Z, Nakkash R. Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students. Tob Control. 2015;24(e1):e72-e80. doi:10.1136/tobaccocontrol-2012-050745
Andrews JC, Netemeyer RG, Burton S, Kees J. Effects of plain package branding and graphic health warnings on adolescent smokers in the USA, Spain and France. Tob Control. 2016;25(e2):e120-e126. doi:10.1136/tobaccocontrol-2015-052583
Blanton H, Snyder LB, Strauts E, Larson JG. Effect of graphic cigarette warnings on smoking intentions in young adults. PLoS One. 2014;9(5):e96315. doi:10.1371/journal.pone.0096315
Byrne S, Greiner Safi A, Kemp D, Skurka C, Davydova J, Scolere L, et al. Effects of varying color, imagery, and text of cigarette package warning labels among socioeconomically disadvantaged middle school youth and adult smokers. Health Commun. 2019;34(3):306-316. doi:10.1080/10410236.2017.1407228
Callery WE, Hammond D, O'Connor RJ, Fong GT. The appeal of smokeless tobacco products among young Canadian smokers: The impact of pictorial health warnings and relative risk messages. Nicotine Tob Res. 2011;13(5):373-383. doi:10.1093/ntr/ntr013
Cameron LD, Pepper JK, Brewer NT. Responses of young adults to graphic warning labels for cigarette packages. Tob Control. 2015;24(e1):e14-e22. doi:10.1136/tobaccocontrol-2012-050645
Do KT, Galvan A. FDA cigarette warning labels lower craving and elicit frontoinsular activation in adolescent smokers. Soc Cogn Affect Neurosci. 2015;10(11):1484-1496. doi:10.1093/scan/nsv038
Evans AT, Peters E, Shoben AB, Meilleur L, Klein E, Tompkins M, et al. Cigarette graphic warning labels are not created equal: They can increase or decrease smokers' quit intentions relative to text-only warnings. Nicotine Tob Res. 2017;19(10):1155-1162. doi:10.1093/ntr/ntw389
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. doi:10.1093/ntr/ntv082
Golmier I, Chebat J-C, Gélinas-Chebat C. Can cigarette warnings counterbalance effects of smoking scenes in movies? Psychol Rep. 2007;100(1):3-18. doi:10.2466/PR0.100.1.3-18
Green AE, Mays D, Falk EB, Vallone D, Gallagher N, Richardson A, et al. Young adult smokers' neural response to graphic cigarette warning labels. Addict Behav Rep. 2016;3:28-32. doi:10.1016/j.abrep.2016.02.001
Gygax PM, Bosson M, Gay C, Ribordy F. Relevance of health warnings on cigarette packs: A psycholinguistic investigation. Health Commun. 2010;25(5):397-409. doi:10.1080/10410236.2010.483334
Hammond D, Thrasher J, Reid JL, Driezen P, Boudreau C, Santillan EA. Perceived effectiveness of pictorial health warnings among Mexican youth and adults: A population-level intervention with potential to reduce tobacco-related inequities. Cancer Causes Control. 2012;23(S1):57-67. doi:10.1007/s10552-012-9902-4
Kessels LTE, Ruiter RAC. Eye movement responses to health messages on cigarette packages. BMC Public Health. 2012;12(1):352. doi:10.1186/1471-2458-12-352
LaVoie NR, Quick BL, Riles JM, Lambert NJ. Are graphic cigarette warning labels an effective message strategy? A test of psychological reactance theory and source appraisal. Communic Res. 2015;44(3):416-436. doi:10.1177/0093650215609669
Macy JT, Chassin L, Presson CC, Yeung E. Exposure to graphic warning labels on cigarette packages: Effects on implicit and explicit attitudes towards smoking among young adults. Psychol Health. 2016;31(3):349-363. doi:10.1080/08870446.2015.1104309
Mutti S, Reid JL, Gupta PC, Pednekar M, Dhumal G, Nargis N, et al. Perceived effectiveness of text and pictorial health warnings for smokeless tobacco packages in Navi Mumbai, India, and Dhaka, Bangladesh: Findings from an experimental study. Tob Control. 2016;25(4):437-443. doi:10.1136/tobaccocontrol-2015-052315
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. doi:10.1093/her/cyu036
O'Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P. Reactions of young adult smokers to warning labels on cigarette packages. Am J Prev Med. 2006;30(6):467-473. doi:10.1016/j.amepre.2006.01.018
Peebles K, Hall MG, Pepper JK, Byron MJ, Noar SM, Brewer NT. Adolescents' responses to pictorial warnings on their parents' cigarette packs. J Adolesc Health. 2016;59(6):635-641. doi:10.1016/j.jadohealth.2016.07.003
Pepper JK, Cameron LD, Reiter PL, McRee AL, Brewer NT. Non-smoking male adolescents' reactions to cigarette warnings. PLoS One. 2013;8(8):e65533. doi:10.1371/journal.pone.0065533
Qin Y, Wu M, Pan X, Xiang Q, Huang J, Gu Z, et al. Reactions of Chinese adults to warning labels on cigarette packages: A survey in Jiangsu Province. BMC Public Health. 2011;11(1):133. doi:10.1186/1471-2458-11-133
Sabbane LI, Bellavance F, Chebat JC. Recency versus repetition priming effects of cigarette warnings on nonsmoking teenagers: The moderating effects of cigarette-brand familiarity. J Appl Soc Psychol. 2009;39(3):656-682. doi:10.1111/j.1559-1816.2009.00455.x
Sabbane LI, Lowrey TM, Chebat JC. The effectiveness of cigarette warning label threats on nonsmoking adolescents. J Consum Aff. 2009;43(2):332-345. doi:10.1111/j.1745-6606.2009.01142.x
Schneider S, Gadinger M, Fischer A. Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Educ Couns. 2012;86(1):77-83. doi:10.1016/j.pec.2011.03.005
Vardavas CI, Connolly G, Karamanolis K, Kafatos A. Adolescents perceived effectiveness of the proposed European graphic tobacco warning labels. Eur J Public Health. 2009;19(2):212-217. doi:10.1093/eurpub/ckp015
Glock S, Kneer J. Are deterrent pictures effective? The impact of warning labels on cognitive dissonance in smokers. Appl Psychol Health Well Being. 2009;1(3):356-373. doi:10.1111/j.1758-0854.2009.01019.x
Magnan RE, Cameron LD. Do young adults perceive that cigarette graphic warnings provide new knowledge about the harms of smoking? Ann Behav Med. 2015;49(4):594-604. doi:10.1007/s12160-015-9691-6
Mutti S, Hammond D, Reid JL, Thrasher JF. The efficacy of cigarette warning labels on health beliefs in the United States and Mexico. J Health Commun. 2013;18(10):1180-1192. doi:10.1080/10810730.2013.778368
Brewer NT, Parada H, Hall MG, Boynton MH, Noar SM, Ribisl KM. Understanding why pictorial cigarette pack warnings increase quit attempts. Ann Behav Med. 2019;53(3):232-243. doi:10.1093/abm/kay032
Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach L, et al. Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. JAMA Intern Med. 2016;176(7):905-912. doi:10.1001/jamainternmed.2016.2621
Brodar KE, Byron MJ, Peebles K, Hall MG, Pepper JK, Brewer NT. "That's probably what my mama's lungs look like": How adolescent children react to pictorial warnings on their parents' cigarette packs. BMC Public Health. 2018;18(1):1125. doi:10.1186/s12889-018-6011-7
Thrasher JF, Abad-Vivero EN, Huang L, O'Connor R, Hammond D, Bansal-Travers M, et al. Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts. Soc Sci Med. 2016;164:141-149. doi:10.1016/j.socscimed.2015.05.042
Morgan JC, Golden SD, Noar SM, Ribisl K, Southwell B, Jeong M, et al. Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence. Soc Sci Med. 2018;218:45-51. doi:10.1016/j.socscimed.2018.09.063
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. doi:10.3390/ijerph121013195
Slovic P. What does it mean to know a cumulative risk? Adolescents' perceptions of short-term and long-term consequences of smoking. J Behav Decis Mak. 2000;13(2):259-266. doi:10.1002/(SICI)1099-0771(200004/06)13:2
Arnett JJ. Optimistic bias in adolescent and adult smokers. Addict Behav. 2000;25(4):625-632. doi:10.1016/S0306-4603(99)00072-6
McKelvey K, Halpern-Felsher B. From tobacco-endgame strategizing to Red Queen's race: The case of non-combustible tobacco products. Addict Behav. 2019;91:1-4. doi:10.1016/j.addbeh.2019.01.001
Dillard JP, Weber KM, Vail RG. The relationship between the perceived and actual effectiveness of persuasive messages: A meta-analysis with implications for formative campaign research. J Commun. 2007;57(4):613-631. doi:10.1111/j.1460-2466.2007.00360.x