The influence of graphic warning labels on efficacy beliefs and risk perceptions: a qualitative study with low-income, urban smokers
More details
Hide details
Department of Health, Behavior and Society, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, U.S.A.
Department of Behavioral and Community Health, University of Maryland School of Public Health, Tobacco Center of Regulatory Science, College Park, U.S.A.
Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, U.S.A.
Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, U.S.A.
Department of Mental Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, U.S.A.
Submission date: 2015-10-08
Acceptance date: 2016-07-01
Publication date: 2016-07-27
Corresponding author
Erin L. Mead   

Department of Health, Behavior and Society, Johns Hopkins University, Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, U.S.A
Tobacco Induced Diseases 2016;14(July):25
Health communication theories indicate that messages depicting efficacy and threat might promote behavior change by enhancing individuals’ efficacy beliefs and risk perceptions, but this has received little attention in graphic warning label research. We explored low socioeconomic status (SES) smokers’ perceptions of theory-based graphic warning labels to inform the development of labels to promote smoking cessation.

Twelve graphic warning labels were developed with self-efficacy and response efficacy messages paired with messages portraying high, low, or no threat from smoking. Self-efficacy messages were designed to promote confidence in ability to quit, while response efficacy messages were designed to promote confidence in the ability of the Quitline to aid cessation. From January – February 2014, we conducted in-depth interviews with 25 low SES adult men and women smokers in Baltimore, Maryland, U.S. Participants discussed the labels’ role in their self-efficacy beliefs, response efficacy beliefs about the Quitline, and risk perceptions (including perceived severity of and susceptibility to disease). Data were analyzed through framework analysis, a type of thematic analysis.

Efficacy messages in which participants vicariously experienced the characters’ quit successes were reported as most influential to self-efficacy beliefs. Labels portraying a high threat were reported as most influential to participants’ perceived severity of and susceptibility to smoking risks. Self-efficacy messages alone and paired with high threat were seen as most influential on self-efficacy beliefs. Labels portraying the threat from smoking were most motivational for calling the Quitline, followed by labels showing healthy role models who had successfully quit using the Quitline.

Role model-based efficacy messages might enhance the effectiveness of labels by making smokers’ self-efficacy beliefs about quitting most salient and enhancing the perceived efficacy of the Quitline. Threatening messages play an important role in enhancing risk perceptions, but findings suggest that efficacy messages are also important in the impact of labels on beliefs and motivation. Our findings could aid in the development of labels to address smoking disparities among low SES populations in the U.S.

World Health Organization. WHO report on the global tobacco epidemic, 2011: Warning about the dangers of tobacco. Geneva: WHO Press; 2011. Accessed May 5, 2014.
World Health Organization. Article 11: Packaging and labelling of tobacco products, WHO Framework Convention on Tobacco Control. Geneva: WHO Press; 2003.
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):708–17. doi:10.1093/ntr/nts194.
Hammond D. Health warning messages on tobacco products: A review. Tob Control. 2011;20(5):327–37. doi:10.1136/tc.2010.037630.
Miller CL, Hill DJ, Quester PG, Hiller JE. Impact on the Australian Quitline of new graphic cigarette pack warnings including the Quitline number. Tob Control. 2009;18(3):235–7. doi:10.1136/tc.2008.028290.
Bansal-Travers M, Hammond D, Smith P, Cummings KM. The impact of cigarette pack design, descriptors, and warning labels on risk perception in the U.S. Am J Prev Med. 2011;40(6):674–82. doi:10.1016/j.amepre.2011.01.021.
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;18(5):358–64. doi:10.1136/tc.2008.028043.
Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz LR, 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. doi:10.1371/journal.pone.0052206.
Kees J, Burton S, Andrews JC, Kozup J. Understanding how graphic pictorial warnings work on cigarette packaging. J Public Policy Mark. 2010;29(2):265–76. doi:10.1509/jppm.29.2.265.
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;11:238. doi:10.1186/1471-2458-11-238.
Thrasher JF, Arillo-Santillan E, Villalobos V, Perez-Hernandez R, Hammond D, Carter J, et al. Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content. Cancer Causes Control. 2012;23 Suppl 1:69–80. doi:10.1007/s10552-012-9899-8.
Mays D, Niaura RS, Evans WD, Hammond D, Luta G, Tercyak KP. Cigarette packaging and health warnings: The impact of plain packaging and message framing on young smokers. Tob Control. 2015;24(e1):e87-92. doi:10.1136/tobaccocontrol-2013-051234.
Zhao X, Nan X, Yang B, Iles IA. Cigarette warning labels: Graphics, framing, and identity. Health Educ. 2014;114(2):101–17. doi:10.1108/HE-06-2013-0024.
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.
Huang L-L, Thrasher JF, Reid JL, Hammond D. Predictive and external validity of a pre-market study to determine the most effective pictorial health warning label content for cigarette packages. Nicotine Tob Res. 2016;18(5):1376–81.
Emery LF, Romer D, Sheerin KM, Jamieson KH, Peters E. Affective and cognitive mediators of the impact of cigarette warning labels. Nicotine Tob Res. 2014;16(3):263–9. doi:10.1093/ntr/ntt124.
Hammond D, Fong GT, McDonald PW, Brown KS, Cameron R. Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. Am J Public Health. 2004;94(8):1442–5. doi:10.2105/ajph.94.8.1442.
Wang AL, Romer D, Elman I, Turetsky BI, Gur RC, Langleben DD. Emotional graphic cigarette warning labels reduce the electrophysiological brain response to smoking cues. Addict Biol. 2015;20(2):368–76. doi:10.1111/adb.12117.
Wang AL, Lowen SB, Romer D, Giorno M, Langleben DD. Emotional reaction facilitates the brain and behavioural impact of graphic cigarette warning labels in smokers. Tob Control. 2015;24(3):225–32. doi:10.1136/tobaccocontrol-2014-051993.
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. doi:10.1093/ntr/nts094.
Peters GJY, Ruiter RAC, Kok G. Threatening communication: A critical re-analysis and a revised meta-analytic test of fear appeal theory. Health Psychol Rev. 2013;7(SUPPL1):S8–S31. doi:10.1080/17437199.2012.703527.
Ruiter CR C, Kok G. Saying is not (always) doing: Cigarette warning labels are useless. Eur J Public Health. 2005;15(3):329. doi:10.1093/eurpub/cki095.
Witte K. Putting the fear back into fear appeals: The extended parallel process model. Commun Monogr. 1992;59(4):329–49. doi:10.1080/03637759209376276.
Witte K, Allen M. A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Educ Behav. 2000;27(5):591–615. doi:10.1177/109019810002700506.
Ruiter RA, Kessels LT, Peters GJ, Kok G. Sixty years of fear appeal research: current state of the evidence. Int J Psychol. 2014;49(2):63–70. doi:10.1002/ijop.12042.
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. doi:10.1371/journal.pone.0054937.
Thrasher JF, Swayampakala K, Borland R, Nagelhout G, Yong H-H, Hammond D et al. Influences of self-efficacy, response efficacy, and reactance on responses to cigarette health warnings: A longitudinal study of adult smokers in Australia and Canada. Health Commun. 2016:1–10. doi:10.1080/10410236.2015.1089456.
Fathelrahman AI, Omar M, Awang R, Borland R, Fong GT, Hammond D, et al. Smokers’ responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine Tob Res. 2009;11(3):248–53.
Berg CJ, Thrasher JF, Westmaas JL, Buchanan T, Pinsker EA, Ahluwalia JS. College student reactions to health warning labels: Sociodemographic and psychosocial factors related to perceived effectiveness of different approaches. Prev Med. 2011;53(6):427–30. doi:10.1016/j.ypmed.2011.09.006.
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.
Gallopel-Morvan K, Gabriel P, Le Gall-Ely M, Rieunier S, Urien B. The use of visual warnings in social marketing: The case of tobacco. J Bus Res. 2011;64(1):7–11. doi:10.1016/j.jbusres.2009.09.012.
Cismaru M, Lavack AM. Tobacco warning labels and the protection motivation model: Implications for Canadian tobacco control policy. Can Public Pol. 2007;33(4):477–86. doi:10.3138/cpp.33.4.477.
Waters EA, McQueen A, Caburnay CA, Boyum S, Sanders Thompson VL, Kaphingst KA, et al. Perceptions of the U.S. National Tobacco Quitline Among Adolescents and Adults: A Qualitative Study, 2012–2013. Prev Chronic Dis. 2015;12:E131. doi:10.5888/pcd12.150139.
Bandura A. On the functional properties of perceived self-efficacy revisited. J Manage. 2012;38(1):9–44. doi:10.1177/0149206311410606.
Beacom AM, Newman SJ. Communicating health information to disadvantaged populations. Fam Community Health. 2010;33(2):152–62. doi:10.1097/fch.0b013e3181d59344.
Viswanath K, Finnegan Jr JR. The knowledge gap hypothesis: Twenty-five years later. In: Burleson BR, Kunkel A, editors. Communication yearbook. Thousand Oaks, CA: Sage Publications, Inc; 1996. p. 187–227.
Viswanath K, Breen N, Meissner H, Moser RP, Hesse B, Steele WR, et al. Cancer knowledge and disparities in the information age. J Health Commun. 2006;11 Suppl 1:1–17. doi:10.1080/10810730600977517.
Kreuter MW, McClure SM. The role of culture in health communication. Annu Rev Public Health. 2004;25:439–55. doi:10.1146/annurev.publhealth.25.101802.123000.
Thrasher JF, Villalobos V, Szklo A, Fong GT, Perez C, Sebrie E, et al. Assessing the impact of cigarette package health warning labels: A cross-country comparison in Brazil, Uruguay and Mexico. Salud Publica Mex. 2010;52 Suppl 2:S206–15. doi:10.1590/s0036-36342010000800016.
Centers for Disease Control and Prevention. Quitting smoking among adults --- United States, 2001–2010. MMWR Morb Mortal Wkly Rep. 2011;60(44):1513–9.
Barbeau EM, Krieger N, Soobader MJ. Working class matters: Socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. Am J Public Health. 2004;94(2):269–78. doi:10.2105/AJPH.94.2.269.
Gilman SE, Abrams DB, Buka SL. Socioeconomic status over the life course and stages of cigarette use: Initiation, regular use, and cessation. J Epidemiol Community Health. 2003;57(10):802–8. doi:10.1136/jech.57.10.802.
Jamal A, Homa DM, O'Connor E, Babb SD, Caraballo RS, Singh T, et al. Current cigarette smoking among adults - United States, 2005–2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1233–40. doi:10.15585/mmwr.mm6444a2.
Mead EL, Cohen JE, Kennedy C, Gallo J, Latkin CA. The role of theory-driven graphic warning labels in motivation to quit: a qualitative study on perceptions from low-income, urban smokers. BMC Public Health. 2015;15:92. doi:10.1186/s12889-015-1438-6.
Baltimore City Health Department. Baltimore city community health survey 2009: Summary results report. 2010. http://health.baltimorecity.go.... Accessed October 23 2014.
LaVeist T, Thorpe Jr R, Mance G, Jackson J. Overcoming confounding of race with socio-economic status and segregation to explore race disparities in smoking. Addiction. 2007;102 Suppl 2:65–70. doi:10.1111/j.1360-0443.2007.01956.x.
Hammond D, Thrasher JF, 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 Suppl 1:57–67. doi:10.1007/s10552-012-9902-4.
Tobin KE, Kuramoto SJ, Davey-Rothwell MA, Latkin CA. The STEP into Action study: A peer-based, personal risk network-focused HIV prevention intervention with injection drug users in Baltimore, Maryland. Addiction. 2011;106(2):366–75. doi:10.1111/j.1360-0443.2010.03146.x.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117.
Block LG, Punam AK. Effects of self-efficacy and vividness on the persuasiveness of health communications. J Consum Psychol. 1997;6(1):31–54. doi:10.2307/1480521.
Popova L. Scaring the snus out of smokers: Testing effects of fear, threat, and efficacy on smokers’ acceptance of novel smokeless tobacco products. Health Commun. 2014;29(9):924–36. doi:10.1080/10410236.2013.824063.
Strahan EJ, White K, Fong GT, Fabrigar LR, Zanna MP, Cameron R. Enhancing the effectiveness of tobacco package warning labels: A social psychological perspective. Tob Control. 2002;11(3):183–90. doi:10.1136/tc.11.3.183.
Bandura A. Social cognitive theory of mass communication. In: Bryant J, Zillman D, editors. Media Effects: Advances in Theory and Research. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum; 2001. p. 121–53.
Anderson RB, McMillion PY. Effects of similar and diversified modeling on African American women's efficacy expectations and intentions to perform breast self-examination. Health Commun. 1995;7(4):327–43. doi:10.1207/s15327027hc0704_3.
Maddison R, Prapavessis H, Clatworthy M. Modeling and rehabilitation following anterior cruciate ligament reconstruction. Ann Behav Med. 2006;31(1):89–98. doi:10.1207/s15324796abm3101_13.
Secker-Walker RH, Solomon LJ, Geller BM, Flynn BS, Worden JK, Skelly JM, et al. Modeling smoking cessation: Exploring the use of a videotape to help pregnant women quit smoking. Women Health. 1997;25(1):23–35. doi:10.1300/J013v25n01_02.
Thrasher JF, Carpenter MJ, Andrews JO, Gray KM, Alberg AJ, Navarro A, et al. Cigarette warning label policy alternatives and smoking-related health disparities. Am J Prev Med. 2012;43(6):590–600. doi:10.1016/j.amepre.2012.08.025.
Kaufman A, Augustson E, Davis K, Finney Rutten LJ. Awareness and Use of Tobacco Quitlines: Evidence from the Health Information National Trends Survey. J Health Commun. 2010;15(0 3):264–78. doi:10.1080/10810730.2010.526172.
Burns EK, Deaton EA, Levinson AH. Rates and Reasons: Disparities in Low Intentions to Use a State Smoking Cessation Quitline. Am J Health Promot. 2011;25(sp5):S59-S65. doi:10.4278/ajhp.100611-QUAN-183.
Solomon LJ, Hughes JR, Livingston A, Naud S, Callas PW, Peters EN, et al. Cognitive barriers to calling a smoking quitline. Nicotine Tob Res. 2009;11(11):1339–46. doi:10.1093/ntr/ntp143.
Smith AL, Carter SM, Chapman S, Dunlop SM, Freeman B. Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers. BMJ Open. 2015;5(4):e007301. doi:10.1136/bmjopen-2014-007301.
Hoek J, Gendall P, Eckert C, Rolls K, Louviere J. A comparison of on-pack Quitline information formats. Tob Control. 2016;25(2):211-7. doi:10.1136/tobaccocontrol-2014-051820.
Maibach E, Murphy DA. Self-efficacy in health promotion research and practice: Conceptualization and measurement. Health Educ Res. 1995;10(1):37–50. doi:10.1093/her/10.1.37.
Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change. Hum Commun Res. 2003;29(3):370–99. doi:10.1111/j.1468-2958.2003.tb00844.x.
Brown SL, Richardson M. The effect of distressing imagery on attention to and persuasiveness of an antialcohol message: A gaze-tracking approach. Health Educ Behav. 2012;39(1):8–17. doi:10.1177/1090198111404411.
Haines-Saah RJ, Bell K, Dennis S. A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom, and the United States. Am J Public Health. 2014;105(2):e61–e9. doi:10.2105/AJPH.2014.302362.
Translating Diverse Environmental Data into Reliable Information
Daniel Vallero
Perceived effectiveness of pictorial health warnings on changes in smoking behaviour in Asia: a literature review
Suci Puspita Ratih, Dewi Susanna
BMC Public Health
Advertising to Kids and Tweens: The Different Effect of Warning Label Attached on the Product Packaging
The Journal of Asian Finance, Economics and Business
“I Quit”: Testing the Added Value and Sequencing Effects of an Efficacy-focused Message among Cigarette Warning Labels
Emma Jesch, Jeff Niederdeppe, Andy King, Amelia Safi, Sahara Byrne
Journal of Health Communication
Testing messages about comparative risk of electronic cigarettes and combusted cigarettes
Bo Yang, Daniel Owusu, Lucy Popova
Tobacco Control
New Zealand roll‐your‐own smokers' reaction to novel roll‐your‐own tobacco packaging warning labels
Mei‐Ling Blank, Janet Hoek, Philip Gendall
Drug and Alcohol Review
Health science knowledge translation: Critical appraisal of online physical activity promotion material
Jafrā Thomas, Bradley Cardinal
Nursing & Health Sciences
A Qualitative Study of Pictorial Health Warnings on Malaysian Cigarette Packs: How Do the Adults Understand Them?
Ainun Hamzah, Roslan Saub, Jamaludin Marhazlinda
A Narrative Review of the Efficacy and Design of Safety Labels on Tobacco Products to Promote the Use of Safety Labels on Alcohol Products in Canada
Man Yau, Kiana Yau, Trana Hussaini, Eric Yoshida
A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT
Terri Voepel-Lewis, Carol Boyd, Alan Tait, Sean McCabe, Brian Zikmund-Fisher
American Journal of Preventive Medicine
Perceived threat and fear responses to e-cigarette warning label messages: Results from 16 focus groups with U.S. youth and adults
Rosemary Avery, Motasem Kalaji, Jeff Niederdeppe, Alan Mathios, Michael Dorf, Sahara Byrne, Amelia Safi, Jesse Kaye
Air Pollution Calculations
Daniel Vallero
Journals System - logo
Scroll to top