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While health warnings are present on cigarette packs around the world, the nature of the warnings varies considerably between countries. In the United States, a small text warning citing the dangers of cigarette smoking is found on the side of all packs. This pilot study sought to determine whether graphic cigarette warning images, like those found in the United Kingdom and Canada, were better at decreasing cravings to smoke than existing text warnings found on cigarette packs in the United States. Twenty-five smokers seeking treatment to quit at a specialty tobacco treatment program were administered the Brief Questionnaire of Smoking Urges (QSU — BRIEF), a validated measure of craving, prior to and following exposure to cigarette pack warning images. The graphic cigarette warning images reduced cravings to smoke (6.20 point decrease) more than neutral images (3.36 point decrease) and current text warnings used in the United States (5.75 point decrease), although this difference was not statistically significant. Based on these pilot data, a larger study could further examine the effectiveness of graphic warning images and whether such warnings hold an advantage over the currently used text warnings.
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85
Lin, P.N., Zimmermann, M.H., Bover Manderski, M.T., Schmelzer, A.C., & Steinberg, M.B. (2011). Evaluation of graphic cigarette warning images on
cravings to smoke. Journal of Smoking Cessation, 6(2), 85–88. DOI 10.1375/jsc.6.2.85
Address for correspondence: Michael B. Steinberg, MD, MPH, FACP, UMDNJ-Robert Wood Johnson Medical School, Tobacco Dependence Program,
Division of General Internal Medicine, Clinical Academic Building — 125 Paterson Street, Room 2300, New Brunswick, NJ 08903, USA. E-mail:
michael.steinberg@umdnj.edu
Background
Tobacco use is the leading cause of preventable death in
the United States and the second major cause of death
worldwide (WHO, 2005). Cigarette smoking is a risk
factor for a variety of diseases, including cancer, heart
disease, stroke and chronic pulmonary disease (U.S.
Surgeon General’s Report, 2004). Despite the well-known
health effects of continued use, tobacco usage and the
resulting sequelae remain a global problem. In an effort to
communicate effectively the health risks associated with
smoking and curb tobacco use among consumers, many
countries have instituted the placement of warning labels
on cigarette packs, with some countries choosing to use
more graphic images (Hammond et al., 2007). More than
140 countries have ratified the Framework Convention on
Tobacco Control (FCTC), which mandates the placement
of warnings on cigarette packs. The FCTC recommends
using 50% of a pack’s surface area to display health infor-
mation and requires covering at least 30% of the pack
surface with a consumer warning that clearly states the
dangers of tobacco use (FCTC, 2005). The current ciga-
rette warning labelling system in the United States, which
consists of a small Surgeon General’s text box placed on
the sides of a cigarette pack, does not meet the minimum
standards set forth by the FCTC (WHO, 2005).
Placement, size, and design contribute to the overall
effectiveness of cigarette warning labels. Research indi-
cates that obscure text warnings used in the United States
and numerous other countries are less effective at being
Evaluation of Graphic Cigarette Warning
Images on Cravings to Smoke
Patrick N. Lin,1Mia Hanos Zimmermann,2Michelle T. Bover Manderski,3Amy C. Schmelzer1
and Michael B. Steinberg1
1
UMDNJ-Robert Wood Johnson Medical School, Tobacco Dependence Program, Division of General Internal Medicine,
United States of America
2UMDNJ-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, United States of America
3UMDNJ-School of Public Health, Center for Tobacco Surveillance & Evaluation Research, United States of America
While health warnings are present on cigarette packs around the world, the nature of the warnings
varies considerably between countries. In the United States, a small text warning citing the
dangers of cigarette smoking is found on the side of all packs. This pilot study sought to determine
whether graphic cigarette warning images, like those found in the United Kingdom and Canada, were
better at decreasing cravings to smoke than existing text warnings found on cigarette packs in the
United States. Twenty-five smokers seeking treatment to quit at a specialty tobacco treatment program
were administered the Brief Questionnaire of Smoking Urges (QSU — BRIEF), a validated measure of
craving, prior to and following exposure to cigarette pack warning images. The graphic cigarette
warning images reduced cravings to smoke (6.20 point decrease) more than neutral images (3.36
point decrease) and current text warnings used in the United States (5.75 point decrease), although
this difference was not statistically significant. Based on these pilot data, a larger study could further
examine the effectiveness of graphic warning images and whether such warnings hold an advantage
over the currently used text warnings.
Keywords: tobacco, craving, graphic, warning, images
ARTICLE AVAILABLE ONLINE
Journal of Smoking Cessation
noticed and remembered in comparison to larger, more
graphic warnings (Hammond et al., 2007). The use of
image-based warning labels has been associated with
greater recall of the health warning, as well as an increase
in both motivation and number of attempts to quit
smoking (Koval, Anbur, Pederson, O’Hegarty, & Chan,
2005). A study by White, Webster, & Wakefield (2008)
found that adolescents in particular can be positively
influenced by warning images; after viewing the images,
adolescents more frequently read, attended to, thought
and talked about warning labels at follow-up. Adolescents
in Greece rated the European Union (EU) images as effec-
tive measures to preventing the initiation of smoking
(Vardavas, Connolly, Karamanolis, & Kafatos, 2009).
As a result of these findings, many countries have
examined the use of graphic images as warning labels and
have demonstrated their effectiveness (Hammond et al.,
2007). Recently, the EU has proposed a new series of
graphic anti-smoking warning images to be used for any
country within the EU. Currently within the EU, Belgium,
Romania and the United Kingdom have instituted the use
of picture warnings; however, the United Kingdom is the
first country to mandate this change on all tobacco prod-
ucts (UK Department of Health, 2009). A commission is
currently underway to update the library of images in
order to spur more countries to adopt an image-based
labelling system (Stafford, 2009).
Despite data supporting the effectiveness of graphic
warnings on message recall and impact on initiation,
there are little data describing the impact of warnings on
cravings to smoke. Craving, defined by Sayette et al.
(2000) as the desire to use a drug, has been implicated as
the most troublesome symptom experienced during
nicotine withdrawal (West, Hajek, & Belcher, 1989). This
pilot study sought to measure the impact of proposed
cigarette warning images on cravings to smoke among
smokers presenting for tobacco dependence treatment at
a specialty clinic.
Methods
Subjects
A sample of 25 consecutive subjects were recruited from a
population of smokers seeking treatment at the
University of Medicine and Dentistry of New Jersey —
Tobacco Dependence Program (TDP) between June 1,
2008 and August 1, 2008. Subjects were approached prior
to or following their appointments at the TDP, and they
were requested to provide written informed consent.
There were no specific exclusion criteria to the study, with
the exception being that the subjects needed to be able to
view all of the images and complete the data collection
instrument, which was only made available in English.
Data Collection
Each subject was administered a baseline questionnaire
measuring demographic and tobacco use characteristics
86 JOURNAL OF SMOKING CESSATION
Patrick N. Lin, Mia Hanos Zimmermann, Michelle T. Bover Manderski, Amy C. Schmelzer and Michael B. Steinberg
followed by an instrument to measure current cravings
to smoke. Demographic data included: age, gender,
race/ethnicity, education, tobacco use history, quitting
history, measures of tobacco dependence, and medical
history. All data was collected with an identification code
that was not linked to any subject identifiers.
Instrument
To systematically measure subjects’ cravings, we utilised
the Brief Questionnaire of Smoking Urges (QSU —
BRIEF), a validated 10-item questionnaire that provides a
composite craving score from 10–70, with higher
numbers indicating higher levels of craving. The QSU —
BRIEF is a modification of the 35-question Questionnaire
of Smoking Urges (QSU; Cox, Tiffany, & Christen, 2001;
Tiffany & Drobes, 1991) and has demonstrated equal
effectiveness as the QSU in gauging subjects’ smoking
craving (Cappelleri et al., 2006).
Protocol
Each subject was asked to complete the QSU-Brief
before looking at any warnings to establish a baseline
reading of the subject’s craving level. In an adapted pro-
tocol from Harris, Mayle, Mabbott, and Napper (2007),
recruited subjects were shown three groups of images in
random order: proposed graphic image warnings, cur-
rently used text warnings, and neutral images (e.g.,
nature photographs). The graphic images were selected
from warnings approved for use in the United Kingdom,
text warnings were selected from US Surgeon General
Warnings, and neutral images were taken from stock
nature images. The proposed images from the EU, as
well as the existing warning images, were obtained from
website sources that have hosted the images for public
use: http://www.smoke-free.ca/warnings/countries
%20and%20laws.htm. After each set of images, cravings
were re-evaluated by completion of a QSU-BRIEF.
A random sequence generator randomised the order of
the sets of images shown to subjects in effort to reduce
collection bias of image presentation.
Results
The characteristics of the participants in the study are
shown in Table 1. Subjects had a mean age of 49 years
(range from 23 to 65). Forty-eight per cent were female,
56% were Caucasian/white, 20% were Hispanic, 16%
were African American, and 8% were Asian/Indian.
Sixteen per cent of subjects had not completed high
school, 36% had graduated from high school, and 48%
had completed some college or graduate work. These
demographics closely matched the overall profile of
patients seen at the clinic. The subjects displayed high
levels of tobacco dependence by smoking a mean of 20
cigarettes per day and smoking their first cigarette on
average at 22 minutes after waking. The mean number
of previous quit attempts among the subjects was three.
Each subject’s total QSU-Brief score (a range of
10–70) represented their craving level at baseline and
after each warning/image viewed. Subjects with higher
QSU-Brief scores displayed higher levels of craving for
cigarettes. The mean scores for each image type were
subtracted from the baseline score to determine the
impact of viewing the image for each subject. The mean
reduction in QSU-Brief craving scores was highest for
the graphic warnings (mean = -6.20 points; standard
deviation (SD) 13.86) compared with text warnings
(mean = -5.75; SD 13.29) and neutral images (mean =
-3.36; SD 9.47), although the difference between each of
the categories of graphic, neutral, and text warnings was
not statistically significant (Figure 1). In addition, 84%
87
JOURNAL OF SMOKING CESSATION
Evaluation of Graphic Cigarette Warning Images on Cravings to Smoke
of subjects identified the graphic images as the most
effective stimuli for motivation to quit smoking. An
overwhelming majority of subjects (88%) rated smoking
as having the most detrimental effect on their health; 10
on a scale ranging from zero (no effect at all) to 10
(most detrimental effect).
Of the images shown, the one image identified as the
most effective was an image of stained teeth that dis-
played the effects of years of smoking. While the subjects
believed that the graphic images evoked a prominent
response, this was not shown in the data collected.
Anecdotally, many subjects stated their profound disin-
terest in cigarettes after seeing the graphic images,
especially after viewing the graphic images. A few sub-
jects stated the calming aspect of the control images
decreased their cravings to smoke.
Discussion
This study found that graphic cigarette warning images
presented to this sample of smokers reduced cravings to
smoke (-6.20 points) more than neutral images (-3.36
points) and current text warnings (-5.75 points). While
there was no statistical difference between the text and
images, the subjects rated the graphic images as the most
effective images in reducing cravings. Results from this
pilot may provide insight on whether image-based cigarette
warnings will be more effective than text warnings on
reducing cravings to smoke and provide support and
therefore provide evidence for implementation by other
countries, such as the United States. Such results would be
helpful given the recent Senate approval of the Family
Smoking Prevention and Tobacco Control Act, passed in June
2009, that enables the Food and Drug Administration
(FDA) to regulate nicotine content and chemicals in
cigarettes, in addition to restricting the advertising and
marketing of cigarettes (Wilson, 2009). The FDA has
proposed new cigarette pack images be implemented in the
near future.
The subject of cigarette packaging as a method of
tobacco control remains a popular one. Many countries
across the world, not just in the EU, are transitioning to
images on cigarette packs. Interestingly, while many
countries seem to be using graphic warning images to
shock, they have not considered the impact of brand
packaging of the cigarette. A study by Wakefield,
Germain, and Henriksen (2008) demonstrated that plain
and unadorned packing made cigarettes contained
within less attractive and desirable. The two extremes of
cigarette packaging should be examined in more detail
in order to determine the best method of control.
The placement of graphic warnings images on ciga-
rette packs has the potential to influence millions of
smokers worldwide to quit smoking. However, there are
many concerns with such graphic image warnings that
need to be addressed in order to act as a better method of
control. Foremost among these concerns is the shock
Table 1
Participant Demographics
Characteristics Values
Age (Mean,
SD
) 49 (11.7)
Gender (
n
, %)
Male 12 (48)
Female 13 (52)
Race (
n
, %)
Asian/Indian 2 (8)
Black 4 (16)
Hispanic 5 (20)
White 14 (56)
Education (
n
, %)
Less than High School 4 (16)
Completed High School 9 (36)
Some College 8 (32)
Completed College 3 (12)
Post Graduate Work 1 (4)
Figure 1
Changes in Mean Craving Score (QSU-Brief) from Stimulus Type
Ͳ6.20
Ͳ5.75
Ͳ3.36
Ͳ7
Ͳ6
Ͳ5
Ͳ4
Ͳ3
Ͳ2
Ͳ1
0
MeanCravingScore
ChangesinMeanCravingScorefrom
StimulusType
Graphic
Text
Neutral
value of these images. A study by Nascimento et al. (2008)
suggested that more arousing warnings that are more
shocking would work more effectively as a method of
tobacco control. While these graphic warning images can
provoke a strong reaction in some individuals, studies
have not shown any negative avoidance of the labels
themselves (Peters et al., 2007). However, after the intro-
duction of graphic warning labels in the United Kingdom,
sales of cigarette cases (large volumes of cigarettes lacking
warning labels) and cigarette pack holders (plastic cases
for a cigarette pack) greatly increased (Day, 2003). While
the graphic images clearly have an effect on people, it
remains to be seen whether they truly can affect a person’s
craving to smoke and their long-term willingness to quit.
As a pilot study, this study was limited by its size and
short duration. The sample size of 25 restricts the impli-
cations of the study. Additionally, as a sample of smokers
who sought face-to-face treatment, it is unclear if these
findings are generalizable to all smokers. A larger study
is necessary to further examine the effectiveness of
graphic warning images and whether such warnings
hold an advantage over the currently used text warnings.
Conclusion
In this study, we examined the effects of graphic cigarette
warnings on subjects’ cravings to smoke and compared
the resulting decrease in cravings to the current text based
warnings used in the United States. While the graphic
warnings led to the largest decrease in cravings to smoke,
the difference in reduction between the text and graphic
warnings was not significant. However, the majority of
the subjects rated the graphic warning images as more
effective stimuli for quitting smoking. As pilot data, this
study can support the decision to implement proposed
stronger warning labels on cigarette packaging in the
United States.
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88 JOURNAL OF SMOKING CESSATION
Patrick N. Lin, Mia Hanos Zimmermann, Michelle T. Bover Manderski, Amy C. Schmelzer and Michael B. Steinberg
... 29 While few studies reported validity data, some studies indicated that measures were validated in previous research. 30,49 Newer studies were more likely to report reliability data for multi-item ...
... 30 Three of the five studies assessing smoking cravings (the extent to which one desires a cigarette) used multiple items (r = 0.33-0.35). 21,49,61,64,66 Lin, for example, used a 10-item questionnaire to assess smoking cravings. 49 Three studies also assessed clarity, two of which used multiple items (r = 0.65). ...
... 21,49,61,64,66 Lin, for example, used a 10-item questionnaire to assess smoking cravings. 49 Three studies also assessed clarity, two of which used multiple items (r = 0.65). 35,41,68 Finally, one study used a single item to measure liking of the warning. ...
Article
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Background.: We sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments, and provide recommendations for future studies. Methods.: Our systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity. Results.: We identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly assessed measures were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Thirty-seven of 68 studies, or 54%, mentioned a theory as informing the study. Conclusions.: Our review found great variability in constructs and measures used to evaluate the impact of cigarette packs pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources. Implications: Robust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for reliable and validated measures.
... After the warning signs were posted, visitors to New York City retail stores who viewed the warning signs (and protobacco advertising) were significantly more likely to report that the signs made them think about the health risks of smoking or quitting smoking compared with those who visited the stores before the warning signs were posted [9]. Similarly, graphic warning labels on cigarette packs have been associated with lower cravings to smoke [16]. ...
... Given the evidence establishing a relationship between warning images and cravings to smoke [16], we hypothesized that participants exposed to antismoking ads would report lower urges to smoke and purchase fewer tobacco products in iShoppe. We also hypothesized that participants exposed to price promotions would report greater urges to smoke and be more likely to purchase tobacco products than those who were not exposed to promotions. ...
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Background Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and antismoking advertisements (ads) are 2 possible interventions for combating POS advertising. Objective The purpose of this analysis was to determine the influence of antismoking ads and promotions on urges to smoke and tobacco purchases. Methods This analysis examined exposure to graphic (graphic images depicting physical consequences of tobacco use) and supportive (pictures of and supportive messages from former smokers) antismoking ads and promotions in a virtual convenience store as predictors of urge to smoke and buying tobacco products among 1200 current cigarette smokers and 800 recent quitters recruited via a Web-based panel (analytical n=1970). We constructed linear regression models for urge to smoke and logistic regression models for the odds of purchasing tobacco products, stratified by smoking status. Results The only significant finding was a significant negative relationship between exposure to supportive antismoking ads and urge to smoke among current smokers (beta coefficient=−5.04, 95% CI −9.85 to −0.22; P=.04). There was no significant relationship between graphic antismoking ads and urge to smoke among current smokers (coefficient=−3.77, 95% CI −8.56 to 1.02; P=.12). Neither relationship was significant for recent quitters (graphic: coefficient=−3.42, 95% CI −8.65 to 1.81; P=.15 or supportive: coefficient=−3.82, 95% CI −8.99 to 1.36; P=.20). There were no significant differences in urge to smoke by exposure to promotions for current smokers (coefficient=−1.06, 95% CI −4.53 to 2.41; P=.55) or recent quitters (coefficient=1.76, 95% CI −2.07 to 5.59; P=.37). There were also no differences in tobacco purchases by exposure to graphic (current smokers: coefficient=0.93, 95% CI 0.67 to 1.29; P=.66 and recent quitters: coefficient=0.73, 95% CI 0.44 to 1.19; P=.20) or supportive (current smokers: coefficient=1.05, 95% CI 0.75 to 1.46; P=.78 and recent quitters: coefficient=0.73, 95% CI 0.45 to 1.18; P=.20) antismoking ads or price promotions (current smokers: coefficient=1.09, 95% CI 0.86 to 1.38; P=.49 and recent quitters: coefficient=0.90, 95% CI 0.62 to 1.31; P=.60). Conclusions The results of this analysis support future research on the ability of supportive antismoking ads to reduce urges to smoke among current cigarette smokers. Research on urges to smoke has important tobacco control implications, given the relationship between urge to smoke and smoking cigarettes, time to next smoke, and amount smoked.
... After the warning signs were posted, visitors to New York City retail stores who viewed the warning signs (and protobacco advertising) were significantly more likely to report that the signs made them think about the health risks of smoking or quitting smoking compared with those who visited the stores before the warning signs were posted [9]. Similarly, graphic warning labels on cigarette packs have been associated with lower cravings to smoke [16]. ...
... Given the evidence establishing a relationship between warning images and cravings to smoke [16], we hypothesized that participants exposed to antismoking ads would report lower urges to smoke and purchase fewer tobacco products in iShoppe. We also hypothesized that participants exposed to price promotions would report greater urges to smoke and be more likely to purchase tobacco products than those who were not exposed to promotions. ...
Preprint
BACKGROUND Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and anti-smoking advertisements (anti-ads) are too possible interventions for combatting these influences. OBJECTIVE The purpose of this analysis was to determine the relationship between anti- ads and price promotions (promos) and urges to smoke and tobacco purchases. METHODS This analysis examined exposure to graphic and supportive anti-ads and promos in a virtual convenience store as predictors of urge to smoke and buying tobacco products among 1,200 current cigarette smokers and 800 recent quitters recruited via an online panel. We used STATA to construct linear regression models for urge to smoke and logistic regression models for tobacco purchases, stratified by smoking status. RESULTS The only significant finding was a significant negative relationship between exposure to supportive anti-ads and urge to smoke among current smokers (Coeff = -5.04, 95%CI: -9.85, -0.22). All other analysis of anti-ads, promos, urges to smoke, and tobacco purchases were not significant for either current smokers or recent quitters at the P >0.05 significance level. CONCLUSIONS The results of this analysis support the potential utility of supportive anti-ads at the POS to influence urge to smoke among current cigarette smokers.
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