Effects of Strengthening Cigarette Pack Warnings on Attention and Message Processing: A Systematic Review

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study

BACKGROUND

In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health.

METHODS

Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels.

RESULTS

Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05).

CONCLUSIONS

Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study

This study compares the impact of pictorial health warning labels (HWLs) and their placements on waterpipe parts (device, tobacco and charcoal packages) on health communication outcomes between waterpipe smokers and nonsmokers in Lebanon. An online randomized crossover experimental study was conducted among young adults (n = 403, August 2021) who observed three conditions of HWLs: pictorial HWLs on the tobacco package, pictorial HWLs on all waterpipe's parts and text-only HWL on the tobacco package in random order. Participants completed post-exposure assessments of health communication outcomes after each image. Using linear mixed models, we examined the differences in the effect of HWL conditions on several outcomes (i.e. warning reactions) between waterpipe smokers and nonsmokers, controlling for confounders (i.e. age, sex). Nonsmokers reported greater attention (β = 0.54 [95% confidence interval: 0.25-0.82]), cognitive elaboration (0.31 [0.05-0.58]) and social interaction (0.41 [0.18-0.65]) for pictorial HWLs on the tobacco packages than text-only compared with smokers. Pictorial HWLs on three parts versus one part elicited higher cognitive reactions and perceived message effectiveness in nonsmokers compared with waterpipe smokers. These findings provide valuable information for policymakers about the potential of implementing HWLs specific to waterpipes to prevent their use among young adults and limit tobacco-related morbidity and mortality in Lebanon.

The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco

Background

Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied.

Design and Methods

Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions).

Results

Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (β = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (β = -0.61, 95% CI:-1.05, -0.18), and harm (β = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (β = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk.

Conclusion

Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.

The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages

BACKGROUND

Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants' intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices.

METHODS

A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data.

RESULTS

After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01-1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14-1.69) and 1.29 (95% CI 1.04-1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample.

CONCLUSIONS

Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers' intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.

Relationship Between Chronic Lung Disease Diagnosis and Susceptibility to E-Cigarette Use in Adults

BACKGROUND

Electronic cigarettes (e-cigarettes) are known to cause adverse pulmonary effects, yet paradoxically, the prevalence of e-cigarette use has increased among individuals with chronic lung disease. We assessed the relationship between chronic lung disease and the susceptibility to e-cigarette use in adults and determined if specific behavioral, social, and environmental factors influence this relationship.

METHODS

We enrolled adults age ≥ 18 y in Alabama with chronic lung disease from university medical clinics (n = 140) and individuals without chronic lung disease (n = 123, reference group) from January 2020-March 2021. A cross-sectional design was used where we administered questionnaires to collect sociodemographic information and assessed susceptibility to e-cigarette use, exposure to social and environmental factors (ie, advertisements, warning labels, special prices, others' e-cigarette vapors, use of an e-cigarette by others in the home, and visiting a web site or online discussion), and behavioral factors (ie, alcohol and cannabis use). Moderation analyses were conducted to determine if any of these factors would modify the association between chronic lung disease and susceptibility to e-cigarette use.

RESULTS

Susceptibility to e-cigarette use was higher among adults without chronic lung disease than among those with chronic lung disease. Noticing e-cigarette warning labels and visiting a web site or online discussion about e-cigarettes were significantly associated with an increased likelihood of susceptibility to using e-cigarettes in both groups. Exposure to e-cigarette vapor from close contacts, special pricing, living with someone who uses e-cigarettes, and cannabis use were significantly associated with an increased likelihood of susceptibility to e-cigarette use in individuals without chronic lung disease. However, our analyses did not indicate a statistically significant interaction between chronic lung disease and any social, environmental, or behavioral factors on susceptibility to e-cigarette use.

CONCLUSIONS

Individuals without chronic lung disease were more susceptible to e-cigarette use than those with chronic lung disease. Although the prevalence of some behavioral and environmental factors differed among individuals with and without chronic lung disease, these factors did not moderate the association between chronic lung disease and susceptibility to e-cigarette use. Longitudinal investigations are warranted to better test the temporal relationships between chronic lung disease, substance use, social and environmental factors, and the susceptibility to e-cigarette use among individuals with chronic lung disease to identify prevention strategies for this population.

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education

INTRODUCTION

We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke.

AIMS AND METHODS

We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

RESULTS

The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

CONCLUSIONS

The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC).

IMPLICATIONS

The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

The Landscape of Cigar Marketing in Print Magazines from 2018-2021: Content, Expenditures, Volume, Placement and Reach

Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018-2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences (i.e., appearances in magazines), translating to $46,504,578 in expenditures. All ads featured the word "enjoy/enjoyment" and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA's efforts to reduce health disparities through regulations and public education.

How the alcohol industry fought against pregnancy warning labels in France. A press coverage analysis spanning 20 years

Background

Drinking alcohol while pregnant is dangerous for health. To inform on this issue, various countries have adopted pregnancy warning labels on alcoholic beverages, including France since 2007, where wine holds deep cultural consonance. The aim of this research was to analyze the arguments put forward by the alcohol industry (producers, distributors, wholesalers, allied industries, trade associations, social aspects and public relations organizations, councilors who publicly defend wine-sector interests) via the press in France: (1) in 2007 when pregnancy warnings were first implemented, and (2) in 2018 when larger pregnancy warnings to increase visibility were proposed but not adopted.

Methods

We used documentary method to analyze the arguments advanced by the alcohol industry in mainstream (national, regional and specialized) press in France from 2000 to 2020, using the Europresse documentary database. Quantitative analysis (number and trend curve of articles, mapping alcohol-industry actors who spoke in the press) and inductive thematic content analysis (analytical framework of the arguments identified) using NVivo software were carried out.

Results

We found a total of 559 relevant press articles in the database, of which 85 were included in the analysis. Peaks in number of publications were found to coincide with the warning label implementation and with the expansion-project schedule. A large majority of the arguments promoted by the alcohol industry contested the pregnancy warnings measure (very few were in favor). They argued that (1) pregnancy warnings were a questionable measure (e.g., ineffective, or the pictogram clearly links alcohol to mortality), (2) pregnancy warnings would have counterproductive effects (on women and the wider economy), (3) better alternatives exist (e.g., targeted prevention programs, prevention by health professionals). A large majority of the actors who spoke in the press came from the winegrowing sector.

Conclusion

This study fills a gap in the Anglosphere research on lobbying against alcohol warnings by analyzing lobbyists' arguments over a 20-year period covering both failed and successful industry lobbying. New findings have emerged that are likely related to the wine-oriented culture of France. In order to counter the alcohol lobbying practices we conclude with a number of public health recommendations.

Do sugar warning labels influence parents' selection of a labeled snack for their children? A randomized trial in a virtual convenience store

Despite growing evidence that warning labels reduce purchases of sugary drinks, less is known about warnings' impact on purchases of sugary snacks. This paper aimed to experimentally test whether a front-of-package label warning about high sugar content ("sugar warning label") would reduce parents' likelihood of selecting a labeled snack versus a non-labeled snack for their child in a food store setting. Participants (n = 2,219 parents of at least one child aged 1-5y) were recruited via an online panel and asked to complete a shopping task in a virtual convenience store. Participants were randomized to one of three labeling conditions: barcode control, text-only sugar warning label, or pictorial sugar warning label. Participants viewed two granola snacks, one labeled and one unlabeled, and selected one for purchase. A post-shopping survey measured secondary outcomes. Predictions and analyses were preregistered on www.clinicaltrials.gov (NCT04381481). Participants exposed to the text or pictorial sugar warning labels were less likely to select the labeled snack than those in the barcode control group (21%, 18%, and 34% respectively; p < 0.001 for both comparisons of warning to control). Relative to the barcode control label, the text and pictorial sugar warning labels resulted in greater attention, anticipated social interactions, negative affect, cognitive elaboration, and perceived message effectiveness, as well as lower perceptions of healthfulness, appeal, and intentions to purchase or consume the product (p < 0.001 for all comparisons of warnings to control). There were no differences in outcomes between text and pictorial sugar warning labels. In conclusion, text and pictorial sugar warning labels reduced parents' likelihood of selecting a labeled granola snack for their children. These results contribute to a growing body of evidence showing that warning labels influence food purchasing behaviors.

Young adults' cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study

OBJECTIVE

Although cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration's 2016 deeming rule established a cigar warning requirement, but it was challenged in federal court for failing to document warning effects on prevention/cessation, thus necessitating an evidentiary base for such requirements. We sought to explore young adult users' understanding of cigarillo risks and addictiveness, as well as their perceptions of current (voluntary) and proposed cigar warning labels.

DESIGN

In December 2020-January 2021, we conducted eight focus groups with young adult cigarillo smokers. We asked participants their first associations of cigarillos and beliefs about product harms/addictiveness, and then discussed existing warning labels and examples of potential pictorial warnings.

SETTING

Focus groups were conducted remotely via the Adobe Connect platform, with participants from 20 US states.

PARTICIPANTS

Participants included 42 young adults (ages 18-29; 50% male), who were recent cigarillo users (ie, past 30 days) or less frequent users (ie, past 12 months).

RESULTS

Participants frequently used cigarillos as blunts and often conveyed uncertainty about cigarillo risks and addictiveness, in general and relative to cigarettes. Participants typically paid little attention to current text warnings, but many expressed that pictorial warnings would more effectively promote knowledge of product risks and discourage use among prospective users.

CONCLUSIONS

US young adult cigarillo users may lack knowledge about product risks and addictiveness. Standardised warning requirements, particularly pictorial labels, may help address this knowledge gap and deter use.

Cigar Warning Noticing and Demographic and Usage Correlates: Analysis from the United States Population Assessment of Tobacco and Health Study, Wave 5

Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.

Gender-Specific Pictorial Health Warnings: Moderation Effects of the Threat Level and Gender

This study examined the effects of gender-specific pictorial health warning labels contingent on their intended gender and threat levels (for females) in forming anti-smoking intentions. We conducted a within-subject design experiment with smokers and nonsmokers in Singapore (N = 100, 50% men). Each participant viewed 10 warning labels-four female-specific (high and low threat), four gender-neutral (high and low threat), and two male-specific (only low threat)-in a random order, evaluating each label on personal relevance, attention, cognitive elaboration, reactance, and intentions to purchase or avoid smoking. The findings showed that females reported greater relevance, attention, elaboration, and intentions to avoid smoking for low threat female-specific warning labels than male-specific or gender-neutral counterparts. Males reported less attention, elaboration, and relevance for low threat male-specific warning labels than female-specific or gender-neutral counterparts. Under high threat conditions, female-specific and gender-neutral warning labels were equally effective for both genders. No differences were observed by smoking status. Overall, gender-specific warning labels are potentially more effective than gender-neutral ones for deterring smoking in women contingent on low threat levels. By providing a deeper understanding of persuasive mechanisms and boundary conditions for the effects of gender specificity, findings can aid health policymakers in developing better gender-responsive interventions.

Does the content and source credibility of health and risk messages related to nicotine vaping products have an impact on harm perception and behavioural intentions? A systematic review

AIMS

To systematically review the literature on (i) whether and how various risk messages about nicotine vaping products (NVPs) alter harm perception and behavioural intentions of smokers and non-smokers and (ii) how trust in sources of NVP risk communication affects message reception and behavioural intentions.

METHODS

Seven electronic databases and reference lists of relevant articles were searched for articles published up to April 2020. Experimental and quasi-experimental studies on message effects and cross-sectional studies on source credibility were included. The Newcastle-Ottawa Scale and the Evidence Project Risk of Bias Tool were used to assess the quality of observational and intervention studies, respectively. For each outcome variable, we indicated whether there was an effect (as a 'yes' or 'no') and used effect direction plots to display information on the direction of effects.

RESULTS

Nicotine addiction messages resulted in greater health and addiction risk perceptions, relative risk messages comparing the health risks of NVPs to cigarette smoking increased the perception that NVPs are less harmful than combustible cigarettes, and a nicotine fact sheet corrected misperceptions of nicotine and NVPs. Smokers' intention to purchase, try or switch to NVPs was higher when exposed to a relative risk message and lower when exposed to nicotine addiction warnings. Trust in NVP risk information from public health agencies was associated with lower odds of; (i) NVP use and (ii) perceiving NVPs as less harmful, whereas those who trusted information from NVP companies were more likely to perceive NVPs as less harmful than combustible cigarettes.

CONCLUSIONS

Relative risk messages may help improve the accuracy of harm perceptions of nicotine vaping products and increase smokers' intentions to quit smoking and/or to switch to vaping, although the literature is nascent.

Psychophysiological responses to hookah tobacco public education messages among young adults

OBJECTIVE

Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting.

METHOD

One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure.

RESULTS

The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks.

DISCUSSION

Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Responses to reduced nicotine cigarette marketing features: a systematic review

OBJECTIVE

To systematically review the literature regarding responses to commercial and public health marketing features for reduced nicotine cigarettes (RNCs) to anticipate potential industry and regulatory actions should an RNC product standard be issued.

DATA SOURCES

We searched PubMed for English-language articles using several keywords for reduced nicotine products, cigarettes and marketing features published through 2020.

STUDY SELECTION

Of 4092 records, 26 studies were retained for review that met criteria focusing on responses to RNC marketing features.

DATA EXTRACTION

Search terms created by the research team were used for review and included independent extraction and coding by two reviewers. Coding was categorised using study design terminology, commercial and public health features in tobacco regulatory science, and their association with individual responses outlined by several message processing outcomes.

DATA SYNTHESIS

Most studies focused on current cigarette smokers and were cross-sectional. Reactions to RNCs and attitudes and beliefs were the most common outcomes measured. For commercial features, articles generally studied RNC advertisements, products and/or descriptors. For public health features, articles studied counter-messaging (eg, warning labels) or general descriptors about nicotine or a reduced nicotine product standard. Commercial features were generally associated with favourable responses. Public health features offset favourable responses across most outcomes, though their efficacy was mixed. Contrasts in results by smoking status are discussed.

CONCLUSIONS

Commercial marketing of RNCs is appealing and may need stronger regulations or communication campaigns to accurately convey risks. Opportunities exist for future research within tobacco regulatory science.

Estimated Prevalence of Smoking and Smoking-Attributable Mortality Associated With Graphic Health Warnings on Cigarette Packages in the US From 2022 to 2100

Importance

Starting in 2022, the US Food and Drug Administration (FDA) plans to require all cigarette packages in the US to display graphic health warnings depicting health harms associated with smoking. The FDA originally planned to implement such warnings in 2012, but tobacco industry litigation delayed the effort.

Objective

To assess the estimated population health outcomes associated with a policy requiring graphic health warnings on cigarette packages in the US and with a 10-year delay in implementation.

Design Setting and Participants

This decision analytical model used simulation modeling of smoking prevalence and smoking-attributable mortality in the US from 2012 to 2100, using the Cancer Intervention and Surveillance Modeling Network smoking population model. The study was conducted from October 2020 to July 2021.

Main Outcomes and Measures

The primary outcomes were annual adult smoking prevalence, smoking-attributable deaths averted, and life-years gained vs the baseline scenario. A baseline scenario assuming no graphic health warnings was compared with expected outcomes of implementing graphic health warnings in 2022 vs 2012. Policy effects were considered under varying assumptions of the association of the policy with smoking initiation and cessation, ranging from most conservative to most optimistic. A maximum smoking reduction scenario in which all smoking would stop by the end of 2022 was evaluated.

Results

In the baseline scenario, an estimated 13.2 million smoking-attributable deaths would have occurred from 2012 to 2100. Under a maximum smoking-reduction scenario, 5.5 million of these deaths would be averted. Implementation of graphic health warnings from 2022 to 2100 would be associated with 539 000 (range, 275 000-794 000) smoking-attributable deaths averted and 7.9 million (range, 4.0-11.6 million) life-years gained, representing less than 10% of the 5.5 million estimated smoking-attributable deaths averted and 81.8 million life-years gained in the maximum smoking-reduction scenario. Implementation from 2012 to 2100 would be associated with 33.2% (range, 32.9%-33.5%) more deaths averted (718 000; range, 365 000 to 1.1 million) and 42.7% (range, 42.3%-43.1%) more life-years gained (11.2 million; range, 5.7-16.6 million) compared with implementation in 2022.

Conclusions and Relevance

This decision analytical model estimated that FDA cigarette graphic health warnings, if implemented in 2022, would be associated with public health benefits. The model also estimated that more smoking-attributable deaths would have been averted if the policy had been implemented in 2012. Industry litigation and delays to implementing tobacco regulations may have been harmful for public health.

Impact of health warning labels on selection and consumption of food and alcohol products: systematic review with meta-analysis

Health warning labels (HWLs) could reduce harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks. A systematic review with meta-analysis using Cochrane methods was conducted to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drink products displaying image-and-text (sometimes termed 'pictorial') and text-only HWLs. Fourteen randomised controlled trials were included, three for alcohol, eleven for food. For the primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared with no HWL (RR=0.74 (95%CI 0.68-0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger (although not statistically significant) effect on selection of image-and-text HWLs (RR=0.65 (95%CI 0.54-0.80)) than text-only HWLs (RR=0.79 (95%CI 0.74-0.85)). These findings suggest significant potential for HWLs to reduce selection of food and alcoholic drinks, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and naturalistic laboratory settings are needed to estimate the potential effects of food and alcohol HWLs.Study registration: PROSPERO 2018 (registration number: CRD42018106522).

Nature and Potential Impact of Alcohol Health Warning Labels: A Scoping Review

Alcohol is toxic to human health. In addition to providing nutritional information, labels on alcohol products can be used to communicate warnings on alcohol-related harms to consumers. This scoping review examined novel or enhanced health warning labels to assess the current state of the research and the key studied characteristics of labels, along with their impact on the studied outcomes. Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched between January 2010 and April 2021, and 27 papers were included in the review. The results found that most studies were undertaken in English-speaking populations, with the majority conducted online or in the laboratory setting as opposed to the real world. Seventy percent of the papers included at least one cancer-related message, in most instances referring either to cancer in general or to bowel cancer. Evidence from the only real-world long-term labelling intervention demonstrated that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Alcohol health warning labels should be seen as tools to raise awareness on alcohol-related risks, being part of wider alcohol policy approaches.

"When the Fun Stops, Stop": An analysis of the provenance, framing and evidence of a 'responsible gambling' campaign

When the Fun Stops, Stop, is a prominent 'responsible gambling' campaign in the UK, originally funded and delivered by the industry-initiated and funded Senet Group. Since the Senet Group's dissolution in 2020, the campaign has been overseen by the Betting and Gambling Council (BGC), the main gambling industry trade body. There has been no prior analysis of the activities, ideas and framing adopted by the Senet Group, who claimed to be acting as an industry 'watchdog' and oversaw what they characterised as a major public education campaign. We collated written and image-based material related to the Senet Group and its When the Fun Stops, Stop campaign from multiple sources. Guided by Entman's four functions of framing, we analysed the Senet Group's framing of the issues it sought to address, particularly harmful gambling, as well as its causes, and the solutions, focusing on the group's main activity: the delivery of the When the Fun Stops, Stop campaign. We also critically appraised an evaluation of the campaign funded by the Senet Group, using the findings to interrogate the stated claims about the campaign's effectiveness. The analysis showed that the Senet Group's framing of the problem, its causes, and proposed responses resemble those adopted by other industries and industry-funded groups. This involves portraying any harms caused by their products as limited to an atypical minority, rejecting upstream determinants of harm, and promoting individually-targeted voluntary measures, all contrary to the evidence of what works in health promotion, and what would characterise a public health approach. Neither the existing evidence base nor the evidence presented by the Senet Group support their claims about the campaign's effectiveness. These findings add to concerns about industry-funded campaigns in other areas. To minimise conflicts of interest, interventions intended to address gambling-related harms, such as public education campaigns, should be evidence-based and developed, implemented and evaluated completely independent of the industry and industry-funded organisations.

Noticing of cannabis health warning labels in Canada and the US

INTRODUCTION

Product labelling and health warnings are important components of regulatory frameworks for consumer products such as tobacco, alcohol and food. However, evidence in the cannabis domain is limited. This study aimed to examine the reach of mandated health warnings on cannabis products using a natural experimental design.

METHODS

Data are from the online International Cannabis Policy Study 2018 and 2019 surveys. Respondents were men and women aged 16 to 65 years in Canada and US states with illegal and legal nonmedical cannabis ("illegal" and "legal" states, respectively) (n = 72 549). Regression models tested differences in noticing health warnings on cannabis packages pre- and post-legalization in Canada, with comparisons to US states, adjusting for cannabis use, cannabis source and sociodemographics.

RESULTS

Respondents in Canada showed a greater increase in noticing warnings (+8.9%) in 2019 (14.7%) versus 2018 (5.8%) than respondents in US "illegal" states (+2.8%) and "legal" states (+3.2%). In 2019, consumers residing in jurisdictions with legal recreational cannabis who purchased from legal retail sources were more likely to report noticing warnings than consumers who obtained cannabis from illegal/unstated sources (Canada: 40.4% vs. 15.3%; US "legal" states: 35.3% vs. 17.0%). Regular cannabis consumers were more likely to notice warnings than less frequent consumers.

CONCLUSION

Mandating warning labels on cannabis products may increase exposure to messages communicating the health risks of cannabis, especially among frequent consumers and those who access the legal market.

Experts' Perceptions of and Suggestions for Cigar Warning Label Messages and Pictorials

INTRODUCTION

Warning labels can be effective tools to inform the public about tobacco risks. However, tobacco warning research has been largely cigarette-centric. This formative study explores potential directions for improving the current warnings for cigars.

AIMS AND METHODS

Between June and August 2019, we conducted interviews with 10 experts about the current cigar warning statements and requirements, the inclusion of pictorials in cigar warnings, and legal issues. Additionally, experts viewed and discussed concept images to pair with existing warning statements, including realistic photographic images and symbolic images (eg, icons, caution symbols).

RESULTS

Experts agreed that cigar warnings should be strengthened (eg, by increasing their size and use of pictorials) to better leverage their potential impact and maintain warning parity with cigarettes. However, perceived challenges exist given the wide variety of cigar products, product terminology, and use patterns. Experts agreed that photographic pictorials of health effects are likely to be more salient, informative, and effective for behavior change than symbolic ones, but may be vulnerable to legal challenges. Symbolic images used in warnings may obtain attention in a less "controversial" way, but may be considered less serious and "factually accurate," increasing legal risks. Experts indicate that cigar educational campaigns can complement warnings and address additional themes, especially aimed at youth, including exposure to chemicals and flavorings and misperceptions that cigars are "natural."

CONCLUSIONS

Additional consumer research is needed to examine the potential public health impact of improving cigar warnings and to support regulatory efforts.

IMPLICATIONS

This study provides feedback from tobacco control experts about the importance of cigar warning labels and directions for future research and improvements. Experts support increasing the size of cigar warnings and adopting pictorials to improve cigar warning impact and maintain warning parity with cigarettes. Experts agreed that photographic pictorials of health effects are likely to be more salient and effective for behavior change than symbolic ones. Given legal challenges, experts discussed potentially prioritizing warning improvements for those cigars used most frequently as cigarette alternatives and by youth. Overall, more cigar warning research is needed to support regulatory efforts.

Youth Exposure to Warnings on Cigar, E-Cigarette, and Waterpipe Tobacco Packages

INTRODUCTION

Studies of tobacco product warnings have focused primarily on the reach and effectiveness of cigarette warnings for adult smokers, whereas few observational studies have examined noncigarette tobacco product warnings among youth.

METHODS

High school students from the 2019 National Youth Tobacco Survey (n=10,094) reported the frequency of exposure to warnings on cigar, e-cigarette, and waterpipe tobacco packages and the perceived harm of occasionally using e-cigarettes and waterpipe tobacco. In 2020, results were analyzed for the entire sample and among subgroups, including never users, ever users, youth susceptible to using tobacco, and current users.

RESULTS

Reported high exposure to warnings was highest for cigars (22.3%), followed by that for e-cigarettes (20.8%) and that for waterpipe tobacco (7.0%). Youth who were susceptible to using cigars (AOR=1.53, 95% CI=1.29, 1.82), who ever used cigars (AOR=4.32, 95% CI=3.57, 5.22), or who currently used cigars (AOR=8.90, 95% CI=6.95, 11.39) were more likely to report high exposure to cigar warnings than youth who never used cigars. Similar findings were observed for e-cigarette and waterpipe tobacco warnings. For youth who ever used e-cigarettes, high exposure to warnings was associated with higher odds of perceiving e-cigarettes as harmful for occasional product use (AOR=1.50, 95% CI=1.05, 2.15), and high exposure to waterpipe tobacco warnings was associated with higher odds of perceiving waterpipe tobacco as harmful (AOR=1.21, 95% CI=1.00, 1.45).

CONCLUSIONS

Warnings on noncigarette tobacco products reach some youth at risk for using these products, but these warnings may need to be strengthened to further reduce their use.

Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings

BACKGROUND

For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS).

AIMS

The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS).

METHOD

Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors.

RESULTS

Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS.

DISCUSSION

Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences.

CONCLUSION

The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

The effectiveness of graphic health warnings on tobacco products: a systematic review on perceived harm and quit intentions

BACKGROUND

Examination of the format and framing of the graphic health warnings (GHWs) on tobacco products and their impact on tobacco cessation has received increasing attention. This review focused on systematically identifying and synthesizing evidence of longitudinal studies that evaluate different GHW formats and specifically considered GHW influence on perceived risk of tobacco use and quit intentions.

METHODS

Ten databases were systematically searched for relevant records in December 2017 and again in September 2019. Thirty-five longitudinal studies were identified and analyzed in terms of the formatting of GHWs and the outcomes of perceived risk and quit intentions. Quality assessment of all studies was conducted.

RESULTS

This review found graphics exceeding 50% of packs were the most common ratio for GHWs, and identified an ongoing reliance on negatively framed messages and limited source attribution. Perceived harms and quit intentions were increased by GHWs. However, wear-out effects were observed regardless of GHW format indicating the length of time warnings are present in market warrants ongoing research attention to identify wear out points. Quit intentions and perceived harm were also combined into a cognitive response measure, limiting the evaluation of the effects of each GHW format variables in those cases. In addition, alternative GHW package inserts were found to be a complimentary approach to traditional GHWs.

CONCLUSIONS

This review demonstrated the role of GHWs on increasing quit intentions and perceptions of health risks by evaluating quality-assessed longitudinal research designs. The findings of this study recommend testing alternate GHW formats that communicate quit benefits and objective methodologies to extend beyond self-report.

Experimental Test of the Educational Impact of the Newly Proposed FDA Graphic Cigarette Warnings Among U.S. Adults

BACKGROUND

In August 2019, the U.S. Food and Drug Administration proposed a set of 13 new graphic warnings for cigarette packaging and advertisements.

PURPOSE

We evaluated these warnings relative to text-only equivalents for their ability to educate the public regarding harms of smoking and influence outcomes associated with quitting.

METHODS

In an experimental within-subjects design, U.S. adult nonsmokers, smokers, and dual smoker/electronic cigarette (e-cigarette) users (N = 412) recruited from an online internet platform evaluated the newly proposed graphic warnings and corresponding text-only warnings on understandability, perceived new knowledge, worry elicited about the content of the warning, discouragement from smoking, and encouragement to use e-cigarettes.

RESULTS

Graphic warnings were generally rated as providing better understanding, more new knowledge, eliciting more worry about harms of smoking, and providing more discouragement from smoking relative to text-only warnings.

CONCLUSIONS

The newly proposed graphic warnings could influence important responses to warnings associated with motivation to reduce smoking.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups

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.

Framing pregnancy-related smoking cessation messages for women of reproductive age

INTRODUCTION

Communicating harms of smoking and benefits of quitting to tobacco users to motivate cessation is critical to reduce the burden of tobacco-related disease. Most messaging strategies focus on health risks of smoking using loss-framing; yet, gain-framed messages to increase confidence in quitting have shown promise for smokers with lower self-efficacy. This study examined the impact of message framing on perceived effectiveness of targeted, pregnancy-related smoking cessation messages among pregnant and not-pregnant smoking women of reproductive age.

METHODS

An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited during January to May 2019 (n = 135). Participants self-reported ratings for 10 pregnancy-related cessation messages (half gain-framed) on a validated perceived effectiveness scale. Multivariable regression analyses were conducted using generalized estimating equations to account for clustering by message themes.

RESULTS

Gain-framed messages were rated significantly higher (0.20; p < 0.01) compared to loss-framed messages for perceived effectiveness, after accounting for quit intentions, self-efficacy to quit, health literacy, cessation risk perceptions, nicotine dependence, and pregnancy status.

CONCLUSIONS

Gain-framed health messages about cessation were deemed to be more effective than loss-framed messages among adult female smokers. Targeted, positively framed messages to highlight the benefits of quitting to women of reproductive age show promise as a strategy to promote smoking cessation.

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents

INTRODUCTION

The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts.

METHODS

Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints.

RESULTS

The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers.

CONCLUSION

Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking.

IMPLICATIONS

Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

The duration effect of pictorial health warnings on tobacco consumption in Mexico

Pictorial health warnings (PHW) were introduced in Mexico by the end of 2010. Different studies have assessed how PHW influence attitude or desire to renounce smoking, but they have not studied the actual effect on the demand of tobacco products. Our objective in this paper is to analyze the effect of duration of pictorial health warnings on consumption of tobacco in Mexico. We assess the influence of different consecutive rounds of pictorial warnings, taking into account their length and the use of repeated images. We use a Dynamic Least Squares model (DOLS) with quarterly data (1994-2015), to estimate the long run demand of cigarettes in Mexico, as a function of per-capita income, the relative price of tobacco, different regulatory measures and the different rounds of pictograms, its duration, and the use of repeated images. We find evidence indicating that the pictorial health warnings have reduced consumption of cigarettes, that the effect has decreased in the last rounds, and that the most effective duration of the rounds is six months. PHW regulation deters consumption; however, its effectiveness decreases over time, suggesting that consumers tend to adapt to images.

Examination of Voluntary Compliance with New FDA Cigar Warning Label Requirements

Objectives

The US Food and Drug Administration (FDA) issued new requirements to strengthen and increase the size of cigar warnings. Although these requirements were challenged in court by the cigar industry, and later struck down, cigar manufacturers had the option of voluntarily complying during the injunction. In this study, we examined voluntary warning compliance on a sample of discarded cigar wrappers.

Methods

Warnings were examined on a sample of 1352 discarded cigar wrappers and packs obtained from 15 census tracts in Oakland, California in February 2019. Warnings were coded for new requirement compliance (ie, sized at 30% or more on front and back of pack).

Results

Overall, 67.3% of wrappers displayed compliant warnings - other wrappers had smaller warnings only on the front (30.6%), only on the back (1.5%) or no warning (0.4%). Cigar warning placement was significantly associated with brand (p < .01), cigar type (p < .01), and unit size (p < .01). The prevalence of warning compliance was at least 90% for 6 brands but ranged from 0% to 65% for others. Compliance was lowest for cigarillos (62.1%) and packs of 3 (27.6%).

Conclusions

Strengthening cigar warnings can help increase their effectiveness, but cigar manufacturers may not voluntarily implement changes fully. Continued surveillance and renewed regulatory efforts are warranted.

Testing Alcohol Labels as a Tool to Communicate Cancer Risk to Drinkers: A Real-World Quasi-Experimental Study

Objective:

This study tested the initial and continued effects of cancer warning labels on drinkers’ recall and knowledge that alcohol can cause cancer.

Method:

A quasi-experiment was conducted to examine changes in the intervention versus comparison site for three outcomes: unprompted and prompted recall of the cancer warning, and knowledge that alcohol can cause cancer. The intervention site applied cancer warning labels to alcohol containers in its liquor store for 1 month, and the two liquor stores in the comparison site did not apply cancer labels. In total, 2,049 unique cohort participants (1,056 male) were recruited at liquor stores in the intervention and comparison sites to participate in surveys 4 months before labels were applied and 2 and 6 months after the cancer label was halted because of alcohol industry interference. Generalized estimating equations tested differences in outcomes between sites over time adjusting for socio-demographics and other covariates.

Results:

Two months after the cancer label, unprompted (+24.2% vs. +0.6%; adjusted odds ratio [AOR] = 32.7, 95% CI [5.4, 197.7]) and prompted (+35.7% vs. +4.1%; AOR = 6.2, 95% CI [3.6, 10.9]) recall increased to a greater extent in the intervention versus comparison site. There was a 10% greater increase in knowledge (+12.1% vs. +11.6%; AOR = 1.1, 95% CI [0.7, 1.5]) 2 months after the cancer label in the intervention versus comparison site. Similar results were found 6 months after the cancer label for all three outcomes.

Conclusions:

In a real-world setting, cancer warning labels get noticed and increase knowledge that alcohol can cause cancer. Additional cancer label intervention studies are required that are not compromised by industry interference.

Effects of Current and Enhanced Tobacco Corrective Messages on Smokers' Intention to Quit Smoking and Intention to Purchase Cigarettes

INTRODUCTION

A federal court has ordered tobacco companies to issue corrective messages to address tobacco-related misperceptions. This study examined the effects of viewing current versus two enhanced versions of tobacco corrective messages on smokers' intention to quit smoking and intention to purchase cigarettes.

METHODS

US adult smokers (N = 803) were randomly assigned to view (1) two current tobacco corrective messages (Current), (2) two corrective messages that include an industry deception statement (Industry Deception), or (3) two corrective messages with an industry deception statement and testimonials of people harmed by smoking (Industry Deception + Testimonial). Outcomes were pretest-posttest change in intentions to quit smoking and posttest intention to purchase cigarette measures.

RESULTS

Intention to quit smoking increased significantly after viewing the Current corrective messages versus baseline. In addition, viewing the Industry Deception + Testimonial messages increased intention to quit smoking compared with the Current corrective condition and the Industry Deception condition. Hispanic smokers had increased intention to quit smoking and decreased intention to purchase cigarettes to a greater degree than non-Hispanic smokers in response to Industry Deception + Testimonial messages. There was no significant difference in intention to purchase cigarettes across conditions.

CONCLUSIONS

Enhancing the current corrective statements by including an industry deception statement and testimonials may strengthen effects and contribute to remedying the effects of tobacco misinformation.

IMPLICATIONS

Previous research has found that draft or proposed versions of tobacco industry corrective messages are effective in correcting beliefs and knowledge. However, studies have not examined how the current court-ordered corrective messages could change intention to quit smoking and intention to purchase cigarettes nor whether enhanced messages could perform better. Study findings suggest that the current corrective messages can increase smokers' intention to quit smoking beyond their baseline intention. More importantly, enhancing corrective messages by including an industry deception statement and testimonial was found to be more effective than current corrective messages. Findings can inform future iterations of tobacco correctives and strategies to reverse the effects of tobacco misinformation.

The Role of Negative Emotions Pre- and Post-Implementation of Graphic Health Warnings: Longitudinal Evidence from South Korea

This longitudinal study investigated the factors that determine the effectiveness of graphic health warnings (GHWs) by comparing 246 South Korean smoker's responses before and after the introduction of the country's new tobacco control policy wherein GHWs were placed on all cigarette packaging. Even though introducing GHWs did not cause immediate changes in smokers' intention to quit smoking or perception of smoking's health risk, GHWs eventually motivated smokers to quit smoking when they experienced negative emotional responses to the newly introduced graphic warnings on cigarette packaging. More importantly, this study found that positive changes in smokers' perceived risk associated with smoking due to the introduction of GHWs mediated a positive relationship between changes in smokers' negative emotions (NE) from text-only warnings to graphic warnings and changes in their intention to quit smoking during the same period. Based on these results, the authors suggest that, for GHW policy to be more effective in motivating smoking cessation, the warnings need to convey images sufficiently unpleasant to induce negative emotional responses among smokers.

Secondhand Smoke Risk Communication: Effects on Parent Smokers' Perceptions and Intentions

This study examined effective strategies to communicate with parent smokers about the risks of secondhand smoke (SHS) exposure to children. An online, between-subjects experimental survey was administered via TurkPrime Panels to recruit participants (N = 623) comprising adult smokers living with children (aged 0-15). Participants were assigned to messages conditions that differed by message recommendation (cessation; cessation+exposure reduction) and format (video; text-only) or to a no-message control. Participants in a message condition viewed a message, and all participants responded to questions about their perceptions and intentions. Parent smokers who viewed either message recommendation reported greater harm perceptions (p <.001), self-efficacy (p <.001), and help-seeking intentions (p <.05) than the no-message control group. Cessation+exposure reduction recommendations elicited greater quit intentions than the no-message control (p <.05). Compared to text-only, videos elicited greater reduce-exposure intentions (p <.05) and interpersonal communication intentions (p <.05). Only videos elicited greater quit intentions (p <.01) and help-seeking intentions (p <.01) than the no-message control. Communication about this topic can be optimized by recommending both cessation and exposure-reduction behaviors (versus cessation only), and by using videos (versus traditional print/text-based materials).

Pictorial Cigarette Pack Warnings Increase Some Risk Appraisals But Not Risk Beliefs: A Meta-Analysis

Pictorial warnings on cigarette packs motivate smokers to quit, and yet the warnings' theoretical mechanisms are not clearly understood. To clarify the role that risk appraisals play in pictorial warnings' impacts, we conducted a meta-analysis of the experimental literature. We meta-analyzed 57 studies, conducted in 13 countries, with a cumulative N of 42,854. Pictorial warnings elicited greater cognitive elaboration (e.g., thinking about the risks of smoking; d = 1.27; p < .001) than text-only warnings. Pictorial warnings also elicited more fear and other negative affect (d = .60; p < .001). In contrast, pictorial warnings had no impact on perceived likelihood of harm (d = .03; p = .064), perceived severity (d = .16; p = .244), or experiential risk (d = .06; p = .449). Thus, while pictorial warnings increase affective and some cognitive risk appraisals, they do not increase beliefs about disease risk. We discuss the role of negative affect in warning effectiveness and the implications for image selection and warning implementation.

Protocol for creating new warnings on cigarette packs and evaluating their efficacy in a randomised experimental setting

INTRODUCTION

Tobacco smoking is one of the leading causes of preventable death. This is not inevitable as tobacco control tools have become more powerful and more effective. Among these, warnings on cigarette packs have proven to be somewhat effective. Our objective is to increase the efficacy of antismoking warnings by using innovative psychological approaches and to create an experimental setting for the evaluation of these new warnings based on behavioural indicators.

METHODS AND ANALYSIS

First, we created new warnings based on three categories of motivational leverage and on harm reduction. New warnings with innovative texts and pictures were designed for each category and inserted on plain packs. We will then use standard indicators to compare their effect to that of control packs: plain pack without warning, plain pack with conventional warning and branded pack with conventional warning. Second, the novelty of our approach will consist in designing an experimental protocol that uses monetary incentives to evaluate the effect of warnings. Subjects will be able to 'sacrifice' part of their participation defrayal to purchase a good whose subjective value is related to one's attitude towards smoking. These monetarily incentivised measures are designed to assess smokers' immediate/mid-term intention to quit and non-smokers' aversion to smoking. In both cases, the monetary amounts individuals accept to sacrifice may be a more reliable measure than declarative responses, which may be distorted by several hypothetical biases. In the end, we should be able to robustly measure the impact of our new warnings between intervention and control groups by using both traditional indicators and our new monetarily incentivised measure.

ETHICS AND DISSEMINATION

The ethics committee of the Groupement des Hôpitaux de l'Institut Catholique de Lille approved the research protocol on 5 July 2019 (CIER 2019-22). Results will be presented at scientific meetings and published.

Numeracy and memory for risk probabilities and risk outcomes depicted on cigarette warning labels

OBJECTIVE

Greater numeracy is associated with higher likelihood to quit smoking. We examined whether numeracy supports learning of numeric health-risk information and, in turn, greater risk perceptions and quit intentions.

METHOD

Adult smokers (N = 696) viewed text warnings with numeric risk information four times each in one of three warning-label types (text-only, low-emotion pictorial [i.e., with image], high-emotion pictorial). They completed posttest measures immediately or 6 weeks later. Emotional reactions to warnings were reported the second time participants viewed the warnings. Numeracy, memory for risk probabilities and risk outcomes, risk perceptions, and quit intentions were assessed postexposures.

RESULTS

Memory for risk probabilities and risk outcomes depended on warning-label type and posttest timing. Consistent with memory-consolidation theory, memory for high- versus low-emotion labels was lower immediately, but declined less for high-than low-emotion labels. Label memory was similar between conditions at 6 weeks. Numeracy predicted overall superior memory (especially for risk probabilities) controlling for health literacy and education. It also indirectly predicted greater risk perceptions and quit intentions via memory. In exploratory analyses, however, the superior recall of risk probabilities of smoking among those higher in numeracy was associated with lower risk perceptions.

CONCLUSIONS

Numeracy is associated with superior risk memory, which relates to greater risk perceptions and quit intentions. More numerate and educated smokers may be better able to quit due to their superior learning of smoking's risks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts

BACKGROUND

Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings.

PURPOSE

In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior.

METHODS

In 2014 and 2015, we recruited 2,149 adult smokers in NC and CA, USA. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the USA's current warnings on the side of cigarette packs) or a pictorial warning (one of the USA's proposed text warnings with pictures on the top half of the front and back of cigarette packs).

RESULTS

Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p < .05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p < .05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p < .05).

CONCLUSIONS

Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers' minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Pictorial Warning Labels and Memory for Cigarette Health-risk Information Over Time

BACKGROUND

Pictorial cigarette warning labels are thought to increase risk knowledge, but experimental research has not examined longer-term effects on memory for health risks named in text.

PURPOSE

To investigate memory-consolidation predictions that high- versus low-emotion warnings would support better long-term memory for named cigarette health risks and to test a mediational model of warning-label effects through memory on risk perceptions and quit intentions.

METHODS

A combined sample of U.S.-representative adult smokers, U.S.-representative teen smokers/vulnerable smokers, and Appalachian-representative adult smokers were randomly assigned to a warning-label condition (High-emotion pictorial, Low-emotion pictorial, Text-only) in which they were exposed four times to nine warning labels and reported emotional reactions and elaboration. Memory of warning-label risk information, smoking risk perceptions, and quit intentions were assessed immediately after exposures or 6 weeks later.

RESULTS

Recall of warning-label text was low across the samples and supported memory-consolidation predictions. Specifically, immediate recall was highest for Low-emotion warnings that elicited the least emotion, but recall also declined the most over time in this condition, leaving its 6-week recall lowest; 6-week recall was similar for High-emotion and Text-only warnings. Greater recall was associated with higher risk perceptions and greater quit intentions and mediated part of warning-label effects on these important smoking outcomes. High-emotion warnings had additional non-memory-related effects on risk perceptions and quit intentions that were superior to text-only warnings.

CONCLUSIONS

High- but not Low-emotion pictorial warning labels may support the Food and Drug Administration's primary goal to "effectively convey the negative health consequences of smoking."

CLINICALTRIALS.GOV IDENTIFIER

NCT03375840.

"I Quit": Testing the Added Value and Sequencing Effects of an Efficacy-focused Message among Cigarette Warning Labels

Many emotional appeal theorists argue that negative affect and efficacy work together to promote adaptive behavioral responses to a threat, yet most research on cigarette warning label messages has not examined the intersection between negative affect, hope, and efficacy. The current study tests effects of exposure, at different points in a sequence, to an efficacy-focused warning label in the context of threat-focused warning labels. We conducted an online, between- and within-subjects experiment with 398 adult smokers, testing the effects of warning label exposure on negative affect, hope, efficacy beliefs, and intentions to quit. Exposure to the efficacy-focused "Quit" label aroused higher levels of reported hope and lower levels of reported negative affect than threat-focused labels. Negative affect increased with each additional exposure to a threat-focused warning label, regardless of the order in which respondents saw the "Quit" label. Exposure to the "Quit" label (within a larger set of three threat-focused labels) led to greater self-efficacy but did not influence response efficacy or intentions to quit. We conclude that "Quit" messaging on warning labels can inspire both hopeful feelings and efficacy beliefs. Future research should identify the optimal balance between threat-focused and hopeful quit messages.

Sugary drink warnings: A meta-analysis of experimental studies

BACKGROUND

Policymakers worldwide are considering requiring warnings for sugary drinks. A growing number of experimental studies have examined sugary drink warnings' impacts, but no research to our knowledge has synthesized this literature. To inform ongoing policy debates, this study aimed to identify the effects of sugary drink warnings compared with control conditions.

METHODS AND FINDINGS

We systematically searched 7 databases on June 21, 2019, and October 25, 2019. We also searched reference lists of relevant articles. Two investigators independently screened titles, abstracts, and full texts to identify peer-reviewed articles that used an experimental protocol to examine the effects of sugary drink warnings compared to a control condition. Two investigators independently extracted study characteristics and effect sizes from all relevant full-text articles. We meta-analyzed any outcome assessed in at least 2 studies, combining effect sizes using random effects meta-analytic procedures. Twenty-three experiments with data on 16,241 individuals (mean proportion female, 58%) were included in the meta-analysis. Most studies took place in Latin America (35%) or the US or Canada (46%); 32% included children. Relative to control conditions, sugary drink warnings caused stronger negative emotional reactions (d = 0.69; 95% CI: 0.25, 1.13; p = 0.002) and elicited more thinking about the health effects of sugary drinks (d = 0.65; 95% CI: 0.29, 1.01; p < 0.001). Sugary drink warnings also led to lower healthfulness perceptions (d = -0.22; 95% CI: -0.27, -0.17; p < 0.001) and stronger disease likelihood perceptions (d = 0.15; 95% CI: 0.06, 0.24; p = 0.001). Moreover, sugary drink warnings reduced both hypothetical (d = -0.32; 95% CI: -0.44, -0.21; p < 0.001) and actual consumption and purchasing behavior (d = -0.17; 95% CI: -0.30, -0.04; p = 0.012). Statistically significant effects were not observed for perceptions of added sugar or positive sugary drink attitudes (p's > 0.10). Moderation analyses revealed that health warnings (e.g., "Beverages with added sugar contribute to obesity") led to greater reductions in hypothetical sugary drink purchases than did nutrient warnings (e.g., "High in sugar"; d = -0.35 versus -0.18; Qb = 4.04; p = 0.04). Limitations of this study include that we did not review grey literature and that we were unable to conduct moderation analyses for several prespecified moderators due to an insufficient number of studies.

CONCLUSIONS

This international body of experimental literature supports sugary drink warnings as a population-level strategy for changing behavior, as well as emotions, perceptions, and intentions.

PROTOCOL REGISTRY

PROSPERO ID 146405.

Testing Alcohol Labels as a Tool to Communicate Cancer Risk to Drinkers: A Real-World Quasi-Experimental Study

OBJECTIVE

This study tested the initial and continued effects of cancer warning labels on drinkers' recall and knowledge that alcohol can cause cancer.

METHOD

A quasi-experiment was conducted to examine changes in the intervention versus comparison site for three outcomes: unprompted and prompted recall of the cancer warning, and knowledge that alcohol can cause cancer. The intervention site applied cancer warning labels to alcohol containers in its liquor store for 1 month, and the two liquor stores in the comparison site did not apply cancer labels. In total, 2,049 unique cohort participants (1,056 male) were recruited at liquor stores in the intervention and comparison sites to participate in surveys 4 months before labels were applied and 2 and 6 months after the cancer label was halted because of alcohol industry interference. Generalized estimating equations tested differences in outcomes between sites over time adjusting for socio-demographics and other covariates.

RESULTS

Two months after the cancer label, unprompted (+24.2% vs. +0.6%; adjusted odds ratio [AOR] = 32.7, 95% CI [5.4, 197.7]) and prompted (+35.7% vs. +4.1%; AOR = 6.2, 95% CI [3.6, 10.9]) recall increased to a greater extent in the intervention versus comparison site. There was a 10% greater increase in knowledge (+12.1% vs. +11.6%; AOR = 1.1, 95% CI [0.7, 1.5]) 2 months after the cancer label in the intervention versus comparison site. Similar results were found 6 months after the cancer label for all three outcomes.

CONCLUSIONS

In a real-world setting, cancer warning labels get noticed and increase knowledge that alcohol can cause cancer. Additional cancer label intervention studies are required that are not compromised by industry interference.

Effects of strengthening alcohol labels on attention, message processing, and perceived effectiveness: A quasi-experimental study in Yukon, Canada

Alcohol labels are one strategy for raising consumer awareness about the negative consequences of alcohol, but evidence to inform labels is limited. This quasi-experimental study sought to test the real-world impact of strengthening health messages on alcohol container labels on consumer attention, message processing (reading, thinking, and talking with others about labels), and self-reported drinking. Alcohol labels with a cancer warning, national drinking guidelines, and standard drink information were implemented in the intervention site, and usual labelling practices continued in the comparison site. Changes in key indicators of label effectiveness were assessed among a cohort of adult drinkers in both the intervention and comparison sites using three waves of surveys conducted before and at two time-points after the alcohol label intervention. Generalized Estimating Equations with difference-in-difference terms were used to examine the impact of the label intervention on changes in outcomes. Strengthening health messages on alcohol container labels significantly increased consumer attention to [Adjusted Odds Ratio (AOR)=17.2, 95%CI:8.2,36.2] and processing of labels (e.g., reading labels: AOR=2.6, 95%CI:1.8,3.7), and consumer reports of drinking less due to the labels (AOR=3.7, 95%CI: 2.0,7.0). Strengthening health messages on alcohol containers can achieve their goal of attracting attention, deepening engagement, and enhancing motivation to reduce alcohol use. Strengthening alcohol labelling policies should be a priority for alcohol control globally.

Health Warnings on Sugar-Sweetened Beverages: Simulation of Impacts on Diet and Obesity Among U.S. Adults

INTRODUCTION

Overconsumption of sugar-sweetened beverage (SSB) is a significant contributor to obesity. Policymakers have proposed requiring health warnings on SSBs to reduce SSB consumption. Randomized trials indicate that SSB warnings reduce SSB purchases, but uncertainty remains about how warnings affect population-level dietary and health outcomes.

METHODS

This study developed a stochastic microsimulation model of dietary behaviors and body weight using the 2005-2014 National Health and Nutrition Examination Surveys, research on SSB health warnings, and a validated model of weight change. In 2019, the model simulated a national SSB health warning policy's impact on SSB intake, total energy intake, BMI, and obesity among U.S. adults over 5 years. Sensitivity analyses varied assumptions about: (1) how warning efficacy changes over time, (2) the magnitude of warnings' impact on SSB intake, and (3) caloric compensation.

RESULTS

A national SSB health warning policy would reduce average SSB intake by 25.3 calories/day (95% uncertainty interval [UI]= -27.0, -23.6) and total energy intake by 31.2 calories/day (95% UI= -32.2, -30.1). These dietary changes would reduce average BMI by 0.64 kg/m² (95% UI= -0.67, -0.62) and obesity prevalence by 3.1 percentage points (95% UI= -3.3%, -2.8%). Obesity reductions persisted when assuming warning efficacy wanes over time and when using conservative estimates of warning impact and caloric compensation. Benefits were larger for black and Hispanic adults than for white adults, and for adults with lower SES than for those with higher SES.

CONCLUSIONS

A national SSB health warning policy could reduce adults' SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.