Does Size Impact Attention and Recall of Graphic Health Warnings?

Abstract

Objective:
To evaluate the attention paid to larger sizes of graphic health warnings (GHWs) embedded within cigarette advertisements so as to assess their impacts on rural smokers.

Methods:
Daily smokers (N = 298) were randomly assigned to view a cigarette advertisement with 3 conditions: 2 intervention conditions with GHW comprising 20% or 33% of the ad area, or a text-only control. Eye-tracking software measured attention in milliseconds. Binary outcome mediation was conducted.

Results:
Intervention participants spent 24% of their time viewing the GHWs, compared to 10% for control (p < .01). The odds of GHW recall in the combined (20% and 33%) intervention group were 3.3 times higher than controls. Total dwell time mediated 33% of the effect of the graphic condition on any recall.

Conclusions:
GHWs in 20% of cigarette advertisement space attracted significantly more attention than text-only warnings; larger GHWs did not increase attention. Attention was significantly associated with warning recall; total time viewing mediated warning recall. Tobacco ads should include GHWs to attract the attention of smokers.

Full text

Tobacco Regulatory Science. 2015;1(2):175-185 175
Cigarette advertising and promotion expen-
ditures in the United States exceed $8.3
billion annually with approximately $23
million spent on magazine advertising.1 is size
of this amount demonstrates that advertising is a
robust communication channel between tobacco
companies and consumers. Exposure to cigarette
advertisements predicts brand loyalty and brand
switching behavior among smokers, and has been
associated with increased cigarette consumption
and continuation of smoking.2 Tobacco product
advertisements are inherently at odds with the
overall intent of health warning labels, which aim
to communicate information about the risks of to-
bacco use and promote cessation. Graphic warning
labels convey the known dangers of tobacco prod-
ucts and are required on tobacco product packag-
ing in over 60 countries globally.3 Most of these
countries also have implemented comprehensive
bans on tobacco advertising, rendering graphic
warnings within advertisements unnecessary.4 In
2009, the United States Congress passed the Fam-
ily Smoking Prevention and Tobacco Control Act,
requiring graphic warnings to be placed on ciga-
Elizabeth G. Klein, Division of Health Behavior & Health Promotion, e Ohio State University College of Public Health, Columbus, OH. Abigail
B. Shoben, Division of Biostatistics, e Ohio State University College of Public Health, Columbus, OH. Sarah Krygowski, Division of Health
Behavior & Health Promotion, e Ohio State University College of Public Health, Columbus, OH. Amy Ferketich, Division of Epidemiology, e
Ohio State University College of Public Health, Columbus, OH. Micah Berman, Division of Health Services, Management and Policy, e Ohio
State University College of Public Health, Columbus, OH. Ellen Peters, Department of Psychology, e Ohio State University College of Arts &
Sciences, Columbus, OH. Rao Unnava, Department of Marketing and Logistics, e Ohio State University Fisher College of Business, Columbus,
OH. Mary Ellen Wewers, Division of Health Behavior & Health Promotion, e Ohio State University College of Public Health, Columbus, OH.
Correspondence Dr Klein; klein.232@osu.edu
Does Size Impact Attention and Recall of
Graphic Health Warnings?
Elizabeth G. Klein, PhD, MPH
Abigail B. Shoben, PhD
Sarah Krygowski, MPH
Amy Ferketich, PhD
Micah Berman, JD
Ellen Peters, PhD
Rao Unnava, PhD
Mary Ellen Wewers, PhD, MPH
Objective: To evaluate the attention paid to larger sizes of graphic health warnings (GHWs) em-
bedded within cigarette advertisements so as to assess their impacts on rural smokers. Methods:
Daily smokers (N = 298) were randomly assigned to view a cigarette advertisement with 3 condi-
tions: 2 intervention conditions with GHW comprising 20% or 33% of the ad area, or a text-only
control. Eye-tracking software measured attention in milliseconds. Binary outcome mediation
was conducted. Results: Intervention participants spent 24% of their time viewing the GHWs,
compared to 10% for control (p < .01). The odds of GHW recall in the combined (20% and 33%)
intervention group were 3.3 times higher than controls. Total dwell time mediated 33% of the
eect of the graphic condition on any recall. Conclusions: GHWs in 20% of cigarette advertise-
ment space attracted signicantly more attention than text-only warnings; larger GHWs did not
increase attention. Attention was signicantly associated with warning recall; total time viewing
mediated warning recall. Tobacco ads should include GHWs to attract the attention of smokers.
Key words: smoking; graphic warning; advertising; eye tracking; health communication
Tobacco Regulatory Science. 2015;1(2):175-185
DOI: http://dx.doi.org/10.18001/TRS.1.2.7

Does Size Impact Attention and Recall of Graphic Health Warnings?
176
rette packaging and on the top 20% of advertise-
ments for cigarettes. Although the Food and Drug
Administration (FDA) issued a rule implementing
this requirement, the FDA’s rule was legally chal-
lenged in 2012,5 and a new graphic warning labels
are under development.6
Although the processing of information in health-
warning messages is complex, to be eective, a crit-
ical rst step is to draw attention so that consumers
can understand, recall, and use the information for
health decision making.7,8 us, attention paid to
health warning labels is hypothesized to be neces-
sary for informing consumers regarding smoking
risks, and it may inuence behavioral intent to quit
smoking.9 We can improve our understanding of
consumer reactions to GHWs (and the eective-
ness of GHW characteristics) through research
using eye-tracking equipment, which allows for
detailed capture of precise eye movements when an
individual is exposed to visual stimuli.10 A limited
number of eye-tracking studies have focused on
GHWs and demonstrated that graphic images draw
greater attention than non-graphic warnings.11,12
Other studies, however, have found that smokers
avoid warnings placed on product packaging.13-15
Regionally, rural residents have a higher preva-
lence of smoking and are more likely to be exposed
to secondhand smoke, creating a disproportionate
increase in risk for tobacco-related illness.16 In ad-
dition, tobacco control campaigns tend to focus on
urban media markets,17 which further reduce the
reach of public health messages among rural resi-
dents. Compared to the rest of the nation, Ohio is
a region with higher rates of smoking, smokeless
and dual use of tobacco products,18 with the high-
est rates observed within the rural, Appalachian
counties of the state.19,20 e nature of tobacco use
in this largely rural region is known to be complex,
with environmental, psychological, and social in-
uences that portray tobacco products as tradi-
tional and normative.21-23 Due to lower penetration
of formal and informal tobacco control policies in
this area,16 it is reasonable to assume residents have
a greater exposure to tobacco use as well as greater
exposure to tobacco marketing which contribute to
the vulnerability to tobacco use for rural Appala-
chian residents.24
Outside of the US, countries have adopted
GHWs, mostly on product packaging,4 that exceed
the recommendations of the Framework Con-
vention on Tobacco Control (FCTC), suggesting
movement toward larger warning messages. As
non-eye-tracking survey data have supported that
warning size increases warning eectiveness,25 the
purpose of this study was to evaluate the attention
paid to larger sizes of health warning labels embed-
ded within cigarette advertisements to assess their
impacts on the vulnerable population of Ohio Ap-
palachian smokers. Our primary hypothesis was
that smokers exposed to larger GHWs would dem-
onstrate increased attention, as measured by eye-
tracking equipment dwell time (in seconds), when
compared to those exposed to smaller GHWs or
text-only warnings. Additionally, we hypothesized
that increased attention (as measured by dwell
time) would mediate an expected association be-
tween larger versus smaller or no GHWs and great-
er recall.
METHODS
Participants
Data were gathered as a part of the Ohio Health
Warning Label (OHWL) study on tobacco users
within a rural, underserved region (Ohio Appa-
lachia) between April and October 2013. A con-
venience sample was recruited using yers and
brochures. Participants were invited to provide per-
ceptions of advertising for consumer products, with
recruitment materials distributed to businesses and
advertisements placed in local newspapers; being a
current smoker was not identied as a requirement
for participation. A phone screening determined if
participants met study eligibility criteria: current
daily cigarette smoker; lifetime history of smoking
at least 100 cigarettes; aged 21 or older; and liv-
ing in one of the 32 counties designated as a part
of Ohio Appalachia. Participants were excluded if
they intended to quit within 30 days or if they had
a history of certain eye conditions, such as macu-
lar degeneration, glaucoma, or cataracts, which are
known to interfere with eye tracking equipment.
Participants who completed the experiment re-
ceived a $50 gift card; those unable to be calibrated
on eye-tracking equipment received a $10 gift card.
Procedures
All research sessions were conducted in private
areas within an oce environment. Trained inter-

Klein et al
Tobacco Regulatory Science. 2015;1(2):175-185 177 DOI: http://dx.doi.org/10.18001/TRS.1.2.7
viewers explained the study and obtained signed
informed consent. Participants were seated com-
fortably in a chair within a typical viewing distance
(24 to 32 inches) from a monitor equipped with
the eye-tracking system and underwent calibration
procedures 3 times to assure data quality before the
initiation of the experiment.
Participants were instructed to imagine they were
ipping through a magazine while they moved at
their own pace through the experiment, answering
an on-screen question after each advertisement in
order to standardize a participant’s gaze between
advertisements. Each participant viewed a total of
6 advertisements; one cigarette ad (always shown
fourth) and 5 others for common consumer prod-
ucts: alcohol; a USB drive; macaroni and cheese
dinner; orange juice; and an energy drink. Table
1 shows the chosen brands, corresponding survey
items, and response categories for each on-screen
survey question.
e cigarette brand selected for this experiment
was based on it not being popular among smok-
ers in Appalachian Ohio (Wewers ME et al, un-
published data, January 2012) and its use of simple
graphic and text imagery. An unpopular brand was
selected to minimize dierential attention and re-
call, as smokers are highly brand loyal, and form
beliefs and perceptions of the product from mar-
keting.12,26,27 All participants viewed the selected
advertisement, and were randomly assigned to
one of 3 warning label study conditions: a control
condition with text only, or a graphic warning la-
bel that covered either 20% or 33% of the ad area
(intervention conditions, referred to as large and
standard graphic, respectively). Intervention con-
ditions diered only on the amount of space that
was occupied within the ad. e amount of space
allocated to the non-warning-label portion of the
advertisement was xed across all conditions; blank
space (consistent with the overall aesthetics of the
ad) varied by condition and was largest in the text-
only condition and smallest in the 33% condition.
Nine versions of the FDA-proposed warning la-
bels28 were used, yielding 27 unique tobacco ad-
vertisements across these 3 study conditions; the
control condition matched the 9 text-only mes-
sages of the warning messages. At the end of the
experiment, a survey was administered by a trained
interviewer. e entire protocol took approximate-
ly 45 minutes to complete.
Measures
Eye tracking measures. BeGaze software (Sen-
soMotoric Instruments, 60 Hz RED System) was
used to display the experimental stimuli (adver-
tisements) and capture the eye-tracking data. For
this analysis, the term “warning label” refers to any
warning message that uses text-only or text and
graphic imagery, “warning text” refers only to the
textual message of the portion of a warning label,
and “graphic image” refers only to the visual im-
agery of a warning label. e primary outcome
measure was dwell time (in seconds) as a measure
of attention on specic areas of interest; these ar-
Table 1
Product Advertisements and Post-advertisement Survey Items from the
Ohio Health Warning Label (OHWL) Study
Product Brand Post-advertisement Survey Item Response Categories
USB Drive iFlashDrive I feel condent using technology. 1-10 scale from strongly agree
to strongly disagree
Orange Juice Tropiciana There is at least one full serving of fruit in 100%
juice.
1-10 scale from strongly agree
to strongly disagree
Macaroni and
Cheese Kraft This product is a healthy choice for my family. 1-10 scale from strongly agree
to strongly disagree
Cigarettes American Spirit I am craving a cigarette right now. 1-10 scale from strongly agree
to strongly disagree
Energy Drink 5 hour energy This product is a safe way to boost my energy. 1-10 scale from strongly agree
to strongly disagree
Alcohol Jose Cuervo This advertisement is meant for people who are…? <18, 18-20, 21+ years old

Does Size Impact Attention and Recall of Graphic Health Warnings?
178
eas were dened a priori for all advertisements
viewed. In particular, areas of interest (AOIs) were
constructed for both the warning label and the ad-
vertisement itself (the non-warning label space).
Figure 1 displays the 3 study conditions. ese
AOIs included the (1) whole advertisement, (2)
warning label, (3) cigarette packages, 2 large blocks
of text with the words (4) “Natural,” (5) “Tastes
better,” (6) a block of the advertisement small text,
(7) graphic warning text (eg, “cigarettes are ad-
dictive”), (8) total graphic warning label, and (9)
Quitline (1-800-QUIT-NOW telephone number).
For each AOI listed above, the following things
were measured: (1) the duration of dwell time in it
in seconds; (2) the proportion of viewing time in it
(calculated based on its duration of dwell time di-
vided by total dwell time on the advertisement): (3)
the rst AOI to be viewed, referred to as the rst
xation; and (4) revisits, measured as the sum of
any repeat views to the AOI after a participant’s ini-
tial viewing. Any sections of the advertisement that
were not viewed were counted as zero revisits.29
Survey measures. Participant recall of the health
warning label was determined by a series of ques-
tions that followed the conclusion of the experi-
ment (eg, “What do you remember about the
cigarette advertisement? You can describe any pic-
tures you remember and all of the words you can
recall.”) No visual aids were given to participants
as a recall aid, and eld sta recorded participant
responses verbatim. Two trained coders (EGK,
SEK) reviewed the responses independently, and
assigned codes dichotomously (yes/no) for several
elements: any recall of the GHW; recall of any el-
ements of the warning text; recall of the graphic
image; and recall of the Quitline (1-800-QUIT
NOW). For all 4 recall elements, the kappa coef-
cient for inter-rater reliability was high, ranging
from 98% to 100% (95% condence interval of
95%-100%); consensus meetings were held to re-
solve coding disagreements.
Survey data were captured by self-report during
the screening process, the experiment, and post-
experiment. Items included demographic factors
of age, race/ethnicity, annual household income,
marital status, and sex. Behavioral factors included
Note.
Areas of interest are labeled as (1) whole advertisement, (2) warning label, (3) packages, (4) “Natural,” (5) “Tastes better,”
(6) advertisement small text, (7) graphic warning text, (8) total graphic warning, (9) Quit line.
Figure 1
Cigarette Warning Advertisements with Study Conditions:
Control, Standard Warning Label, Large Warning Label
A. Control label B. 20% warning label (standard) c. 33% warning label (large)

Klein et al
Tobacco Regulatory Science. 2015;1(2):175-185 179 DOI: http://dx.doi.org/10.18001/TRS.1.2.7
age of smoking initiation (in years), score (0 to 6)
on the Heaviness of Smoking index,30 and a history
of quitting smoking for at least 24 hours (yes/no).
Analysis
Eye-tracking measures were compared among all
3 conditions. Dierences in continuous outcome
measures by group were assessed via ANOVA F-
tests. No gross violations of the equal variance as-
sumption of ANOVA were found in any of the
continuous variables assessed. Dierences in bi-
nary outcomes (including any recall) were assessed
via Wald chi-square tests. If the primary compari-
son (among all groups) was statistically signi-
cant, pairwise comparisons were done using Tukey
(ANOVA) and Bonferroni (chi-square) post hoc
tests.31
Binary outcome mediation32 analysis by logistic
regression was used to explore the possibility that
dwell time on the warning label mediated the eect
of study condition on recall of the warning label.
For these analyses only, the 2 graphic conditions
were collapsed into one group so that the com-
parison was graphic versus text warning. Briey,
mediation analysis decomposes the total eect (c)
into the mediated (indirect) eect (ab) and the di-
rect eect (c’). If all of the eect of the treatment
(graphic condition) could be explained by the me-
diator (dwell time), the remaining direct eect (af-
ter adjustment for the mediator) would be null.
Statistical signicance was set at .05, and no ad-
justments were made for multiple comparisons.
Due to the highly correlated outcomes, a Bonfer-
roni correction (using alpha = .0029) is likely con-
servative. e sample size was estimated based on
modest dierences published in previous research.11
Table 2
Descriptive Characteristics of Appalachian Smokers from the Ohio Health Warning Label
(OHWL) Study
OHWL study (N = 298)
Participant Characteristics
Total
(N = 298)
Text Only
(N = 103)
Standard Graphic
(N = 97)
Large Graphic
(N = 98)
Demographics
Male 33.2% 32.0% 34.0% 33.7%
Mean age (SD) (in years) 40.5 (11.7) 39.7 (11.8) 40.5 (10.5) 41.5 (12.8)
Mean (SD) household size 3.0 (1.5) 3.1 (1.6) 3.2 (1.6) 2.8 (1.4)
% Household income
<$15,000 37.9% 43.7% 33.0% 36.7%
$15-$24,999 27.2% 25.2% 25.8% 30.6%
$25-$34,999 15.8% 14.6% 20.6% 12.2%
$35-$49,999 10.4% 9.7% 10.3% 11.2%
≥$50,000 8.7% 6.8% 10.3% 9.2%
% Education
<High school 22.5% 25.2% 18.6% 23.5%
High school 45.0% 43.7% 45.4% 45.9%
>High school 32.5% 31.1% 36.0% 30.6%
Has health insurance 68.8% 67.0% 73.2% 66.3%
Smoking Behaviors
Mean age (SD) of initiation 17.5 (5.6) 17.6 (5.8) 17.6 (6.2) 17.3 (4.9)
% (n) Ever made serious quit attempt 80.5% (239) 83.5% (86) 81.4% (79) 76.3% (74)
Mean (SD) years smoking 21.9 (11.9) 20.7 (11.8) 22.5 (10.6) 22.7 (13.2)
Mean (SD) cigarettes per day 18.1 (8.7) 18.1 (8.7) 17.3 (8.4) 18.8 (9.1)
Mean (SD) heaviness of smoking index 2.98 (1.52) 2.96 (1.47) 2.93 (1.58) 3.04 (1.5)

Does Size Impact Attention and Recall of Graphic Health Warnings?
180
Data were analyzed using SAS 9.3 (SAS Institute,
Inc.; Cary, North Carolina) and STATA 13 (Stata-
Corp; College Station, Texas).
RESULTS
Overall, 300 participants completed the eye-
tracking experiment and post-experiment survey;
12 participants were unable to be calibrated to the
eye tracking equipment and 2 participants were ex-
cluded from the nal analyses due to problems with
incomplete eye-tracking data. e nal sample (N
= 298) was mostly female (66%), with an average
age of 40 years; most participants (~65%) had low-
er educational attainment (high school or less) and
lower income (below $25,000 annual household
income) as the data in Table 2 show. e mean age
of becoming a regular smoker was 17.5 years and
participants reported an average of 21 years smok-
ing. Participants smoked an average of 18 cigarettes
per day and the mean heaviness of smoking was
2.98, approximately equal to the cuto of 3.0 that
denes high nicotine dependence.33 e major-
ity smoked Marlboro (61%) and none reported
current use of the experimental brand (data not
Table 3
Means (SD) and Proportions (N) for Dwell Times and Fixations by Condition of Warning
Label and Non-warning Label of a Cigarette Advertisement from the Ohio Health Warning
Label (OHWL) Study
OHWL study (N = 298) Text only
(N = 103)
Standard graphic
(N = 97)
Large graphic
(N = 98) p-value
Seconds of Dwell Time (SD)
Comparison alcohol ad 7.66 (4.11) 6.87 (3.87) 7.32 (4.50) .42
Cigarette ad (including warning label) 12.74 (9.36) 11.60 (7.52) 12.81 (9.46) .56
“Natural” 0.87 (1.15) 0.72 (0.64) 0.60 (0.50) .06
“Tastes better” 1.40 (1.79) 1.11 (1.15) 0.97 (1.20) .09
Cigarette packages 1.66 (1.39) 1.31 (1.40) 1.25 (1.14) .03 b
Ad small text 3.63 (5.19) 2.25 (3.59) 2.59 (3.82) .06
Warning label 0.99 (1.20) 2.36 (1.94) 2.53 (1.83) < .01 a,b
Percentage of Total Time
% on warning label 9.6 (11.7) 24.1 (17.4) 24.7 (16.8) < .01a,b
% on warning text only 9.6 (11.7) 10.4 (9.9) 11.2 (10.4) .50
% on graphic image only* -- 13.7 (12.5) 13.7 (11.2) .99
% on Quitline*-- 1.3 (2.3) 1.4 (2.3) .59
Fixation and Revisits
First xation on warning label 21.4% (n=22) 40.2% (n=39) 41.8% (n=41) < .01 a,b
Fixated on warning label 85.4% (n=88) 92.8% (n=90) 91.8% (n=90) .17
# of revisits to warning label** 0.6 (0.9) 1.3 (1.4) 1.3 (1.2) < .01 a,b
* These comparisons include only individuals in the 2 intervention conditions had the opportunity to view the
graphic warning elements
** Amongthosewhoxatedonthewarninglabelatleastonce
Note.
Shaded boxes indicate p < .05 when the 3 conditions were compared
SD = standard deviation
a=Pairwisecomparisonoftextvsstandardgraphicsignicant
b=Pairwisecomparisonoftextvslargegraphicsignicant
c=Pairwisecomparisonofstandardgraphicvslargegraphicsignicant

Klein et al
Tobacco Regulatory Science. 2015;1(2):175-185 181 DOI: http://dx.doi.org/10.18001/TRS.1.2.7
shown.) Participants were balanced between study
conditions, and no statistically signicant dier-
ences existed in demographic characteristics among
study conditions.
Viewing of the Advertisement
Table 3 summarizes the viewing patterns by study
condition. e entire cigarette advertisement in-
cluding the warning label was viewed, on average,
for 12 seconds by participants in all 3 conditions
(F=0.58, df=2, p = .56); total dwell time for the
comparison advertisements did not dier signi-
cantly by condition but was shorter than the ciga-
rette advertisement (result for the alcohol ad shown
in the rst row of Table 3; other data not shown
are available by request). ere were statistically
signicant dierences in the mean dwell time on
the cigarette packages by study condition (F=3.67,
df=2, p = .03). ere were no other statistically sig-
nicant dierences in the dwell time paid to other
(non-warning) cigarette advertisement elements by
study condition.
Total dwell time on the warning label was high-
er in both graphic conditions compared to the
text-only condition (F=25.7, df=2, p < .01). Par-
ticipants in both intervention conditions spent ap-
proximately 24% of their dwell time viewing the
warning label, compared to less than 10% of the
dwell time for control participants (F=31.2, df=2,
p < .01). Almost twice as many participants in the
intervention conditions viewed the warning label
rst, compared to those in the control condition
(42%, 40%, and 21% in the large graphic, stan-
dard graphic, and text-only conditions, respec-
tively; χ2=11.6, df=2, p = .03). Participants in both
intervention conditions averaged 1.3 revisits to the
area of the warning label, compared to 0.6 revisits
for those in the control condition (F=9.5, df=2, p
< .01).
Recall of the Warning Label and Mediation by
Dwell Time
Because there were no statistically signicant dif-
ferences in dwell time between the 2 intervention
conditions, these graphic conditions were collapsed
for the mediation analysis. Recall of any portion of
the warning label was higher in both graphic condi-
tions (56% and 63%, respectively, in the large and
standard graphic groups) compared to the text-only
control condition (31%; χ2=22.7, p < .01; Table 4).
Participants in the 2 graphic conditions were simi-
lar with respect to recall of the graphic image itself,
the text of the warning label, and the Quitline.
Mediation Analysis
In the unadjusted analysis, the odds of any re-
call of the warning label in the combined graphic
warning label group were 3.3 times the odds of any
recall in the control group. After adjusting for to-
tal dwell time on the warning label, this odds ratio
decreased to 2.3 (Figure 2); total dwell time medi-
ated 33% of the eect of graphic condition on any
recall. is eect was statistically signicant as the
bootstrapped 95% CI excluded 0 (95% CI: 15%
to 67%).
DISCUSSION
Our study is the rst to evaluate the impact of
Table 4
Percentage of Any Unaided Recall of Graphic Warning Label Elements by Condition from the
Ohio Health Warning Label (OHWL) Study
OHWL study (N = 298) Control
(N = 103)
20%
(N = 97)
33%
(N = 98) p-value
Any warning label recall (N) 31% (32) 63% (61) 56% (55) < .01
Any text element recall (N) 16% (16) 27% (26) 20% (20) 0.15
Any graphic image recall (N) a-- 40% (39) 39% (38) 0.84
Quit line recall (N) a-- 6% (6) 4% (4) 0.51
Note.
Shaded boxes indicate p < .05
a = These comparisons include only individuals in the intervention conditions who viewed the graphic warning elements

Does Size Impact Attention and Recall of Graphic Health Warnings?
182
warning label size within cigarette advertisements
on consumer attention. It provides empirical sup-
port for the proposition that graphic warning la-
bels occupying at least 20% of advertising space
attract signicantly greater attention than smaller
text only warnings. Not only did they attract more
attention, but this attention mediated the eects
of graphicness on memory for the warnings. In
other words, having a graphic warning compared
to a text-only warning caused greater attention to
be drawn to it which, in turn, led to greater recall
of the warning. Research on graphic warning labels
implemented outside the US has indicated that
warning label size is related to warning eective-
ness, measured by reading and noticing GHWs,
cognitive responses of thoughts of harm or quit-
ting, or behavioral intentions to change smoking
behavior.9,34 Although we did not nd that increas-
ing the size of graphic warnings from 20% to 33%
of an advertisement’s space signicantly increased
smokers’ attention or attracted repeat views, our
ndings support that smokers are attending to and
recalling health warning messages. Attention and
noticing GHWs stimulate reactions from smokers
that predict quit attempts.9
Our ndings regarding the proportion of time
spent on the advertisement relative to the warning
label demonstrated that graphic warnings not only
attract attention, but distract smokers from view-
ing other visual portions of the advertisement. We
believe these ndings highlight the importance of
the GHWs themselves, as well as the context in
which they are viewed by consumers. Two smaller
eye-tracking studies where participants avoided
pack-based warning messages, instead focused on
cigarette brand information.13,35 Both studies used
non-preferred brands of cigarette packs rather than
product advertisements; thus, GHWs on cigarette
packs may produce dierent responses from the
same GHWs in advertisements. Alternatively, it
may be that consumers’ attention threshold was
reached at 20% of advertisements space; additional
studies are warranted to explore means to attract the
attention of smokers to GHWs in advertisements,
as it is critically important to make the warnings
less “invisible” to the consumer’s eye. Advertising
studies have investigated the issue of congruency, or
t between the advertiser and the editorial content,
and found improved consumer recognition of ad-
vertisements and incongruency improved attention
and recall.36-38 Regardless of placement on tobacco
products or advertisements, future research also is
needed to improve understanding of warning-label
factors that can be optimized to avoid message fa-
tigue and sustain positive eects on consumers,
especially considering that tobacco advertisements
Figure 2
Diagram of Mediation Analysis

Klein et al
Tobacco Regulatory Science. 2015;1(2):175-185 183 DOI: http://dx.doi.org/10.18001/TRS.1.2.7
are likely to change in response to GHWs being
added to advertising space.25
Regardless of the presence on packs or within
ads, our results contribute to a robust research base
demonstrating that GHWs are more eective at
inuencing consumer attention and/or desirable
tobacco reduction behaviors than text-only messag-
es.12,25,35,39-50 As the research on GHWs continues
to grow, additional research is needed to under-
stand the optimum characteristics of warning la-
bels within advertisements for all tobacco products,
including those products that will be newly subject
to FDA regulation following the FDA “deeming”
process announced in April 2014.51
e present research has some important limita-
tions. Participants were excluded if they intended
to quit smoking in the next month, so the current
ndings may not be applicable to smokers with
immediate quit intentions. Although brain imag-
ing studies have demonstrated variations in the
response to individual GHW imagery,39 the pres-
ent study was not powered to evaluate dierences
among the 9 individual GHWs viewed, as roughly
30 participants viewed each of the warnings. Each
participant viewed a single advertisement of a non-
dominant cigarette brand that used textual and
graphic components. Such an ad may produce dif-
ferent results from advertisements that use other
types of images, including people and preferred
brands. Further, we cannot evaluate whether the
use of an implicit health claim (the emphasis on
the word “Natural” within the ad) impacted smok-
ers’ attention or recall. e selected study design
also did not include a text-only condition at 20%
of the advertisement space, so we cannot determine
whether greater attention could be attracted with a
larger text-only warning label. Nonetheless, our re-
sults suggest a consistency in the total viewing time
regardless of the portion of space allocated to the
health warning, and a reduction in time spent on
one ad component that appeared due to the pres-
ence versus absence of a graphic image rather than
being based on the portion of allocated space to
the health warning. e unaided recall was coded
as any mention of warning label elements, and did
not dierentiate between recall of text message or
warning imagery. e present study focused on ru-
ral smokers, but future studies should consider ru-
ral residences along with other vulnerable tobacco
users including youth, young adults, and others
considered high-risk tobacco users.
Graphic warning labels are used around the globe;
they are recommended as an eective tobacco con-
trol tool on both products and advertisements.
e guidelines for the Framework Convention on
Tobacco Control (FCTC) note that each country
“whose constitution or constitutional principles
impose constraints on undertaking a comprehen-
sive ban should, under Article 13 of the Conven-
tion, apply restrictions that are as comprehensive
as possible in the light of those constraints.”52
Given that the First Amendment likely precludes
a comprehensive ban on tobacco advertising in the
US, the FDA instead should move forward with
requiring graphic health warnings on tobacco
advertisements.
IMPLICATIONS FOR TOBACCO
REGULATION
Understanding the optimum characteristics of
health warning labels is critically important for
policymakers to consider as they seek to reduce the
prevalence of smoking. Although the images used
in the present study will be redesigned by the FDA,
our ndings support the value of placing warning
labels on at least 20% of the area of tobacco ad-
vertisements, as required by the Family Smoking
Prevention and Tobacco Control Act. Our results
provide empirical support for the use of graphic
warnings within cigarette advertising as a means to
attract attention of smokers.
Human Subjects Approval Statement
e study protocol was approved by e Ohio
State University Institutional Review Board.
Conict of Interest Disclosure Statement
All authors of this article declare they have no
conicts of interest.
Acknowledgments
Research reported in this publication was sup-
ported by grant number R01CA129771-03S1from
the National Cancer Institute and FDA Center
for Tobacco Products (CTP). e content is sole-
ly the responsibility of the authors and does not
necessarily represent the ocial views of the Na-

Does Size Impact Attention and Recall of Graphic Health Warnings?
184
tional Institutes of Health or the Food and Drug
Administration.
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