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Comparing perceived effectiveness of FDA-proposed cigarette packaging graphic health warnings between sexual and gender minorities and heterosexual adults



In 2012, the U.S. Food and Drug Administration proposed nine graphic health warnings (GHWs) on cigarette packaging that were rated equally effective across racial/ethnic, education, or income groups of adult smokers. However, data on GHW effectiveness among sexual and gender minority (SGM) adults, who have higher smoking prevalence, are currently lacking. This study analyzed whether perceived effectiveness of GHWs differed by gender and sexual orientation.


Data came from a randomized experiment among 1,200 adults with an oversample from low socioeconomic status groups, conducted between 2013 and 2014 in three Massachusetts communities. Participants viewed and rated the effectiveness of nine GHWs. Mixed effects regression models predicted perceived effectiveness with gender and sexual orientation, adjusting for repeated measurements, GHWs viewed, age, race, ethnicity, smoking status, and health status.


Female heterosexuals rated GHWs as more effective than male heterosexual, lesbian, and transgender and other gender respondents. There was no significant difference between female and male heterosexuals versus gay, male bisexual, or female bisexual respondents. Differences by gender and sexual orientation were consistent across all nine GHWs. Significant correlates of higher perceived effectiveness included certain GHWs, older age, being African-American (vs white), being Hispanic (vs non-Hispanic), having less than high school education (vs associate degree or higher), and being current smokers (vs non-smokers).


Perceived effectiveness of GHWs was lower in certain SGM groups. We recommend further studies to understand the underlying mechanisms for these findings and investments in research and policy to communicate anti-smoking messages more effectively to SGM populations.

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This work was conducted with support from the National Cancer Institute’s Lung Cancer Disparities Center Grant #P50CA148596 and NIH Grant Number R25 CA057711. R.H.N. acknowledges the support from the Building Interdisciplinary Research Careers in Women’s Health Grant (K12-HD055887) from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development, the Office of Research on Women’s Health, and the National Institute on Aging, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard University or the National Institutes of Health. No financial disclosures were reported by the authors of this paper.

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Correspondence to Andy S. L. Tan.

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Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The university’s institutional review board approved the study.

Informed consent

Written informed consent was obtained from all individual participants included in the study.


Appendix 1

See Table 3.

Table 3 Comparison of perceived effectiveness of nine GHWs by gender and sexual orientation status (n = 1,168)

Appendix 2

See Table 4.

Table 4 Characteristics of study participants by gender and sexual orientation in Boston, Lawrence, and Worcester, 2013

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Tan, A.S.L., Bigman, C.A., Nagler, R.H. et al. Comparing perceived effectiveness of FDA-proposed cigarette packaging graphic health warnings between sexual and gender minorities and heterosexual adults. Cancer Causes Control 28, 1143–1155 (2017). https://doi.org/10.1007/s10552-017-0954-3

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  • Tobacco cigarettes
  • Graphic health warnings
  • Perceived effectiveness
  • Sexual and gender minorities
  • Message testing
  • United States