Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers’ Cigarette Packs

Abstract Background Tobacco consumption is the leading cause of death worldwide. Overwhelming studies demonstrate graphic warning labels (GWLs) on cigarette packs are effective in eliciting negative response to tobacco smoking, modifying beliefs about tobacco dangers, and increasing reported intention to quit, but the estimated effect of GWLs on smoking cessation intention among smokers is still limited in China. In this study, we aim to understand the smoking intensity, smoking duration and smoking cessation intention among current smokers, and to explore how their smoking cessation intention would be influenced by the GWLs in Shanghai. Methods From January to June 2021, we totally recruited 1104 current smokers in Songjiang district and Fengxian district of Shanghai by multistage sampling design. We used Android pad assisted electronic questionnaire for data collection, and then implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore how smoking cessation intention would be influenced by the GWLs among current smokers. Results One thousand one hundred four current smokers included 914 males (82.79%), with an average age of 43.61 years. 58.06% of current smokers reported smoking cessation intention due to GWLs. Logistic regression indicated a higher percentage of smoking cessation intention due to GWLs was among female smokers [OR = 2.41, 95% CI (1.61–3.59)], smokers with smoking intensity < 20 cigarette/day [OR = 1.92, 95% CI (1.44–2.55)], smokers with tobacco burden < 20% [OR = 1.94, 95% CI (1.35–2.79)], and among smokers had plan to quit in a year [OR = 6.58, 95% CI (4.71–9.18). Smokers with higher individual monthly income had lower percentage of smoking cessation intention (OR were 0.35, 0.46 and 0.41). Meanwhile, among 642 current smokers without plan to quit in a year, approximately 40% of them reported smoking cessation intention due to GWLs. Conclusions Smoking cessation intention due to the assumed GWLs on cigarette packs is high among current smokers in Shanghai, especially in female smokers, smokers with light tobacco burden and mild nicotine dependence. Incorporating smoking intensity as well as smoking burden into the implementation of GWLs as tobacco control measures would discourage smoking in China.

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Addiction Treatment Clients’ Reactions to Graphic Warning Labels on Cigarette Packs

Journal of Drug Issues ◽

10.1177/0022042617699196 ◽

2017 ◽

Vol 47 (3) ◽

pp. 433-447 ◽

Cited By ~ 1

Author(s):

Anna Pagano ◽

Noah Gubner ◽

Barbara Tajima ◽

Deborah Yip ◽

Catherine Henderson ◽

...

Keyword(s):

Addiction Treatment ◽

Treatment Programs ◽

Emotional Impact ◽

Warning Labels ◽

Graphic Warning ◽

Group Interviews ◽

Readiness To Quit ◽

Specific Reactions ◽

Diverse Groups ◽

Cigarette Packs

Graphic warning labels (GWLs) on cigarette packs have been tested among diverse groups at high risk for tobacco use. However, little is known about the effectiveness of GWL interventions for persons with substance use disorders, whose smoking prevalence is 3 to 4 times that of the general population. After a experimental study which exposed clients in residential addiction treatment to GWLs for 30 days, we conducted five focus groups with trial participants ( N = 33) to explore how exposure to the labels may have impacted their readiness to quit smoking. Focus group interviews were analyzed thematically. Interviewees reported that GWLs were more effective than text-based warnings for increasing quit intentions due to greater cognitive and emotional impact. Male and female interviewees expressed gender-specific reactions to the labels. Addiction treatment programs are a strategic site for GWL and other tobacco interventions due to the tobacco-vulnerable populations they serve.

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Does Visual Attention to Graphic Warning Labels on Cigarette Packs Predict Key Outcomes among Youth and Low-income Smokers?

Tobacco Regulatory Science ◽

10.18001/trs.4.6.3 ◽

2018 ◽

Vol 4 (6) ◽

pp. 18-37 ◽

Cited By ~ 2

Author(s):

Sahara Byrne ◽

Motasem Kalaji ◽

Jeff Niederdeppe

Keyword(s):

Visual Attention ◽

Low Income ◽

Warning Labels ◽

Graphic Warning ◽

Cigarette Packs

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Tool to assess appeal–aversion response to graphic warning labels on cigarette packs among US smokers

Tobacco Control ◽

10.1136/tobaccocontrol-2019-055520 ◽

2020 ◽

pp. tobaccocontrol-2019-055520 ◽

Cited By ~ 1

Author(s):

Matthew D Stone ◽

Claudiu V Dimofte ◽

David R Strong ◽

Adriana Villasenor ◽

Kim Pulvers ◽

...

Keyword(s):

Nicotine Dependence ◽

Discrete Choice ◽

Assessment Tool ◽

Cigarette Price ◽

Warning Labels ◽

Packaging Design ◽

Current Cigarette ◽

The Usa ◽

Graphic Warning ◽

Cigarette Packs

IntroductionGraphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal–aversion assessment tool to help regulators choose among graphic packaging options.MethodsAfter familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal–aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017–2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated.ResultsAmong purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=−US$2.53, 95% CI: −US$2.76 to −US$2.31; teeth damage=−US$2.90, 95% CI: −US$3.17 to −US$2.63; and gangrenous foot=−US$3.70, 95% CI: −US$4.01 to −US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal–aversion valuations were moderated by sex, income and nicotine dependence (p<0.05).ConclusionsSmokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal–aversion tool could be useful for regulators to differentiate between graphic warning labels.

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FDA withdraws from fight over graphic warning labels on cigarette packs

Cancer ◽

10.1002/cncr.28206 ◽

2013 ◽

Vol 119 (13) ◽

pp. 2361-2361

Author(s):

Carrie Printz

Keyword(s):

Warning Labels ◽

Graphic Warning ◽

Cigarette Packs

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Effect of Graphic Warning Labels on Cigarette Packs on US Smokers’ Cognitions and Smoking Behavior After 3 Months

JAMA Network Open ◽

10.1001/jamanetworkopen.2021.21387 ◽

2021 ◽

Vol 4 (8) ◽

pp. e2121387

Author(s):

David R. Strong ◽

John P. Pierce ◽

Kim Pulvers ◽

Matthew D. Stone ◽

Adriana Villaseñor ◽

...

Keyword(s):

Smoking Behavior ◽

Warning Labels ◽

Graphic Warning ◽

Cigarette Packs

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Graphic Warning Labels Affect Hypothetical Cigarette Purchasing Behavior among Smokers Living with HIV

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16183380 ◽

2019 ◽

Vol 16 (18) ◽

pp. 3380

Author(s):

Lauren Pacek ◽

Meredith Berry ◽

Olga Rass ◽

Melissa Mercincavage ◽

F. McClernon ◽

...

Keyword(s):

Hiv Positive ◽

Purchasing Behavior ◽

Warning Label ◽

Purchasing Decisions ◽

Warning Labels ◽

Cigarette Pack ◽

Valuation Task ◽

Graphic Warning ◽

Living With Hiv ◽

Cigarette Packs

Cigarette pack graphic warning labels (GWLs) are associated with increased knowledge of tobacco-related harms; scant research has evaluated their effects on behavior among vulnerable populations. We used a behavioral economic approach to measure the effects of GWLs and price on hypothetical cigarette purchasing behavior among HIV-positive smokers. Participants (n = 222) completed a cigarette valuation task by making hypothetical choices between GWL cigarette packs at a fixed price ($7.00) and text-only warning label cigarette packs at increasing prices ($3.50 to $14.00; $0.25 increments). More than one-quarter (28.8%) of participants paid more to avoid GWLs. The remaining participants’ purchasing decisions appear to have been driven by price: 69.8% of participants chose the cheaper pack. Across all participants, overall monetary choice value observed for GWL cigarette packs (mean = $7.75) was greater than if choice was driven exclusively by price ($7.00). Most (87.4%) preferred the text-only warning label when GWL and text-only cigarette packs were equally priced. Correlation analysis indicated GWL pack preference was associated with agreement with statements that GWLs would stop individuals from having a cigarette or facilitate thoughts about quitting. These data suggest that GWLs may influence some HIV-positive smokers in such a way that they are willing to pay more to a void seeing GWLs.

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Assessing the Consequences of Implementing Graphic Warning Labels on Cigarette Packs for Tobacco-Related Health Disparities

Nicotine & Tobacco Research ◽

10.1093/ntr/ntv082 ◽

2015 ◽

Vol 17 (8) ◽

pp. 898-907 ◽

Cited By ~ 25

Author(s):

Laura Gibson ◽

Emily Brennan ◽

Ani Momjian ◽

Dina Shapiro-Luft ◽

Holli Seitz ◽

...

Keyword(s):

Health Disparities ◽

Warning Labels ◽

Graphic Warning ◽

Cigarette Packs

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Graphic warning labels on plain cigarette packs: Will they make a difference to adolescents?

Social Science & Medicine ◽

10.1016/j.socscimed.2011.12.043 ◽

2012 ◽

Vol 74 (8) ◽

pp. 1269-1273 ◽

Cited By ~ 37

Author(s):

Judith McCool ◽

Lisa Webb ◽

Linda D. Cameron ◽

Janet Hoek

Keyword(s):

Warning Labels ◽

Graphic Warning ◽

Cigarette Packs

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Should Graphic Warning Labels Proposed for Cigarette Packages Sold in the United States Mention the Food and Drug Administration?

Nicotine & Tobacco Research ◽

10.1093/ntr/ntaa142 ◽

2020 ◽

Author(s):

Mia Jovanova ◽

Chris Skurka ◽

Sahara Byrne ◽

Motasem Kalaji ◽

Amelia Greiner Safi ◽

...

Keyword(s):

Middle School ◽

Tobacco Control ◽

Drug Administration ◽

Source Credibility ◽

Food And Drug Administration ◽

The United States ◽

Smoking Prevention ◽

Warning Labels ◽

The Us ◽

Graphic Warning

Abstract Introduction Under the US Family Smoking Prevention and Tobacco Control Act, the US Food and Drug Administration (FDA) has the authority to implement graphic warning labels (GWLs) on cigarette packages. Neither the original labels proposed by the FDA nor the revised labels include a source to indicate sponsorship of the warnings. This study tests the potential impact of adding a sponsor to the content of GWLs. Methods We recruited adult smokers (N = 245) and middle-school youth (N = 242) from low-income areas in the Northeastern US. We randomly assigned participants to view one of three versions of the original FDA–proposed warning labels in a between-subjects experiment: no sponsor, “US Food and Drug Administration,” or “American Cancer Society” sponsor. We tested the effect of varying sponsorship on source attribution and source credibility. Results Compared to unsponsored labels, FDA sponsorship increased source attributions that the FDA sponsored the labels among both middle-school, largely nonsmoking youth and adult smokers. However, sponsorship had no effect on source credibility among either population. Conclusions We found no evidence that adding FDA as the source is likely to boost source credibility judgments, at least in the short term; though doing so would not appear to have adverse effects on credibility judgments. As such, our data are largely consistent with the Tobacco Control Act’s provisions that allow, but do not require, FDA sponsorship on the labels. Implications This study addresses the FDA’s regulatory efforts by informing the possible design and content of future cigarette warning labels. Our results do not offer compelling evidence that adding the FDA name on GWLs will directly increase source credibility. Future work may test more explicit FDA source labeling and continue to examine the credibility of tobacco message content among high–priority populations.

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