While these recent reviews have summarised portions of the cigarette pack warnings literature, 8, 9, 30 no meta-analysis has synthesised the experimental literature on pictorial cigarette pack warnings. Importantly, this review did not examine many factors that are likely pre-requisites to changes in behaviour, such as attention to warnings, cognitive and emotional reactions to warnings, and changes in beliefs about smoking. Monarrez-Espino et al found that most of these studies were of poor methodological quality for this reason, their findings on the impact of pictorial warnings on smoking behaviour were inconclusive. A systematic review by Monarrez-Espino et al 30 examined 21 mostly observational studies of the impact of pictorial warnings on reduced smoking, quit attempts and smoking cessation. While useful and an important contribution for understanding pictorial warnings, this review did not provide a systematic, quantitative synthesis of pictorial warning effects. A narrative review by Hammond 8 suggested that cigarette pack warnings can be effective in promoting smoking cessation, especially when warnings are large, full-colour, and use graphic images. Reviews of the literature on pictorial cigarette pack warnings have taken a variety of approaches. 27–29 For instance, studies have found that graphic, pictorial warnings result in poorer recall than less graphic or non-graphic warnings, 28 do not increase youth's expectations to be non-smokers a year later, 29 have no effect on beliefs about cancer or addiction among non-smoking adolescent boys, 26 and are effective in lowering smoking intentions for Canadians but not for Americans. 10, 15–21 However, while some studies find that smokers and non-smokers rate pictorial warnings as more effective than text-only warnings, 22–26 other studies have reported conflicting findings. 13, 14 Compared with text-only warnings, pictorial warnings have been associated with stronger beliefs about the harms of smoking and higher motivation to quit smoking. Some evidence suggests that pictures and imagery may be more effective than text-only messages at communicating health risks. Previous research on pictorial cigarette pack warningsĪ large and growing empirical literature has documented the effects of pictorial cigarette pack warnings. For this reason, experiments are an important tool for studying the effects of pictorial warnings. 8, 12 By contrast, experiments can offer strong evidence of the causal impact of pictorial warnings, isolating the effects of warnings on key outcomes. However, isolating the effects of pictorial warnings on smoking behaviour in such studies has proven difficult because governments often introduce the warnings alongside other tobacco control policies. 8, 9 Observational studies suggest increased cessation behaviour after the introduction of pictorial warnings, 10, 11 and such studies typically have high external validity. 7Īs pictorial cigarette pack warnings have proliferated globally, so has research on their impact. 6 By 2015, implementation of pictorial warning policies had occurred in 77 countries and jurisdictions that are home to nearly 50% of the world's population. 6 The treaty's Article 11 specifies that health warnings may include pictures, and subsequent guidelines for implementation state that pictorial warnings are ‘far more effective’ than text-only messages. The WHO Framework Convention on Tobacco Control (FCTC) calls for the implementation of large warnings on tobacco products. The combination of high exposure, nearly universal reach, and very low cost has made pictorial warnings on cigarette packs a core tobacco control strategy globally. Messages on these packs would generate exposure far outweighing exposure from other antitobacco communications, such as mass media campaigns. 4 A pack-a-day smoker potentially sees a cigarette pack an estimated 7300 times per year (20 views/day×365 days/year). 1 While tobacco product packaging is a key part of marketing efforts to make tobacco use appealing, 2, 3 regulators can use that same packaging to communicate the health risks of tobacco products to consumers. Tobacco use is the leading cause of preventable death and disease in the world, causing nearly six million deaths each year.
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