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.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Johnson SE, Holder-Hayes E, Tessman GK et al (2016) Tobacco product use among sexual minority adults: findings from the 2012–2013 National Adult Tobacco Survey. Am J Prev Med 50:e91–e100. doi:10.1016/j.amepre.2015.07.041
Corliss HL, Wadler BM, Jun H-J et al (2013) Sexual-orientation disparities in cigarette smoking in a longitudinal cohort study of adolescents. Nicotine Tob Res 15:213–222. doi:10.1093/ntr/nts114
Cochran SD, Bandiera FC, Mays VM (2013) Sexual orientation-related differences in tobacco use and secondhand smoke exposure among us adults aged 20 to 59 years: 2003–2010 National Health and Nutrition Examination Surveys. Am J Public Health 103:1837–1844. doi:10.2105/AJPH.2013.301423
Buchting FO, Emory KT, Scout et al (2017) Transgender use of cigarettes, cigars, and e-cigarettes in a national study. Am J Prev Med 53:e1–e7. doi:10.1016/j.amepre.2016.11.022
Blosnich JR, Horn K (2011) Associations of discrimination and violence with smoking among emerging adults: differences by gender and sexual orientation. Nicotine Tob Res 13:1284–1295. doi:10.1093/ntr/ntr183
Blosnich JR, Lee JGL, Horn K (2013) A systematic review of the aetiology of tobacco disparities for sexual minorities. Tob Control 22:66–73. doi:10.1136/tobaccocontrol-2011-050181
Newcomb ME, Heinz AJ, Birkett M, Mustanski B (2014) A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. J Adolesc Health 54:558–564. doi:10.1016/j.jadohealth.2013.10.208
Pachankis JE, Hatzenbuehler ML, Starks TJ (2014) The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Soc Sci Med 103:67–75. doi:10.1016/j.socscimed.2013.10.005
Hatzenbuehler ML, Wieringa NF, Keyes KM (2011) Community-level determinants of tobacco use disparities in lesbian, gay, and bisexual youth: results from a population-based study. Arch Pediatr Adolesc Med. doi:10.1001/archpediatrics.2011.64
American Lung Association (2010) Smoking out a deadly threat: tobacco use in the LGBT community. Washington, DC
Lee JGL, Goldstein AO, Ranney LM et al (2011) High tobacco use among lesbian, gay, and bisexual populations in West Virginian bars and community festivals. Int J Environ Res Public Health 8:2758–2769. doi:10.3390/ijerph8072758
Smith EA, Malone RE (2003) The outing of Philip Morris: advertising tobacco to gay men. Am J Public Health 93:988–993. doi:10.2105/AJPH.93.6.988
Smith EA, Offen N, Malone RE (2005) What makes an ad a cigarette ad? Commercial tobacco imagery in the lesbian, gay, and bisexual press. J Epidemiol Community Health 59:1086–1091. doi:10.1136/jech.2005.038760
Stevens P, Carlson LM, Hinman JM (2004) An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention. Health Promot Pract 5:129S–134S. doi:10.1177/1524839904264617
Washington HA (2002) Burning love: big tobacco takes aim at LGBT youths. Am J Public Health 92:1086–1095. doi:10.2105/AJPH.92.7.1086
Dilley JA, Spigner C, Boysun MJ et al (2008) Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob Control 17:385–390. doi:10.1136/tc.2007.024216
Smith EA, Thomson K, Offen N, Malone RE (2008) “If you know you exist, it’s just marketing poison”: meanings of tobacco industry targeting in the lesbian, gay, bisexual, and transgender community. Am J Public Health 98:996–1003. doi:10.2105/AJPH.2007.118174
Clarke T, Ward B, Freeman G, Schiller J (2015) Early release of selected estimates based on data from the January-March 2015 National Health Interview Survey. Centers for Disease Control and Prevention National Center for Health Statistics, Atlanta
Centers for Disease Control and Prevention (2014) The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA
Hill S, Amos A, Clifford D, Platt S (2014) Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tob Control 23:e89–e97. doi:10.1136/tobaccocontrol-2013-051110
Lorenc T, Petticrew M, Welch V, Tugwell P (2013) What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health 67:190–193. doi:10.1136/jech-2012-201257
Thomas S, Fayter D, Misso K et al (2008) Population tobacco control interventions and their effects on social inequalities in smoking: systematic review. Tob Control 17:230–237. doi:10.1136/tc.2007.023911
Lee JGL, Matthews AK, McCullen CA, Melvin CL (2014) Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review. Am J Prev Med 47:823–831. doi:10.1016/j.amepre.2014.07.051
Matthews PA, Block AC, Lee JGL, et al (2017) Position Statement: Support Policies to Reduce Smoking Disparities for Gender and Sexual Minorities. http://www.sbm.org/UserFiles/file/lgbt_smoking_disparities_statement_final.pdf. Accessed 20 Jul 2017
Hammond D (2011) Health warning messages on tobacco products: a review. Tob Control 20:327–337. doi:10.1136/tc.2010.037630
Canadian Cancer Society (2016) Cigarette package health warnings: international status report, 5th edn. Canada
Noar SM, Hall MG, Francis DB et al (2016) Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 25:341–354. doi:10.1136/tobaccocontrol-2014-051978
Brewer NT, Hall MG, Noar SM et al (2016) Effect of pictorial cigarette pack warnings on changes in smoking behavior: a randomized clinical trial. JAMA Intern Med 176:905–912. doi:10.1001/jamainternmed.2016.2621
Tobacco Control Legal Consortium (2013) Cigarette graphic warnings and the divided federal courts. Tobacco Control Legal Consortium, St Paul, MN
Gibson L, Brennan E, Momijan A et al (2015) Assessing the consequences of implementing graphic warning labels on cigarette packs for tobacco-related health disparities. Nicotine Tob Res 17:898–907. doi:10.1093/ntr/ntv082
Cantrell J, Vallone DM, Thrasher JF et al (2013) Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment. PLoS ONE 8:e52206. doi:10.1371/journal.pone.0052206
Dillard JP, Weber KM, Vail RG (2007) The relationship between the perceived and actual effectiveness of persuasive messages: a meta-analysis with implications for formative campaign research. J Commun 57:613–631. doi:10.1111/j.1460-2466.2007.00360.x
Bigsby E, Cappella JN, Seitz HH (2013) Efficiently and effectively evaluating public service announcements: additional evidence for the utility of perceived effectiveness. Commun Monogr 80:1–23. doi:10.1080/03637751.2012.739706
Ackerson LK, Viswanath K (2009) The social context of interpersonal communication and health. J Health Commun 14:5–17. doi:10.1080/10810730902806836
Kontos EZ, Viswanath K (2011) Cancer-related direct-to-consumer advertising: a critical review. Nat Rev Cancer 11:142–150
Viswanath K, Ramanadhan S, Kontos EZ (2007) Mass media. Macrosocial determinants population health. Springer, New York, pp 275–294
Grier SA, Kumanyika S (2010) Targeted marketing and public health. Annu Rev Public Health 31:349–369. doi:10.1146/annurev.publhealth.012809.103607
Sierra JJ, Hyman MR, Heiser RS (2010) A review of ethnic identity in advertising. Wiley International Encyclopedia of Marketing
National Cancer Institute (2008) The role of the media in promoting and reducing tobacco use. U.S. Department of Health & Human Services, National Institutes of Health, National Cancer Institute, Bethesda, MD
Pollay RW, Lee JS, Carter-Whitney D (1992) Separate, but not equal: racial segmentation in cigarette advertising. J Advert 21:45–57. doi:10.1080/00913367.1992.10673359
Schooler C, Basil MD, Altman DG (1996) Alcohol and cigarette advertising on billboards: targeting with social cues. Health Commun 8:109–129. doi:10.1207/s15327027hc0802_1
Knobloch-Westerwick S, Appiah O, Alter S (2008) News selection patterns as a function of race: the discerning minority and the indiscriminating majority. Media Psychol 11:400–417. doi:10.1080/15213260802178542
Matthews AK, Balsam K, Hotton A et al (2014) Awareness of media-based antitobacco messages among a community sample of LGBT individuals. Health Promot Pract 15:857–866. doi:10.1177/1524839914533343
Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities (2011) The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. National Academies Press (US), Washington (DC)
Oakenfull G (2007) Effects of gay identity, gender and explicitness of advertising imagery on gay responses to advertising. J Homosex 53:49–69. doi:10.1080/00918360802101278
Bigman CA, Nagler RH, Viswanath K (2016) Representation, exemplification, and risk: resonance of tobacco graphic health warnings across diverse populations. Health Commun 31:974–987. doi:10.1080/10410236.2015.1026430
Hammond D, Thrasher J, Reid JL et al (2012) Perceived effectiveness of pictorial health warnings among Mexican youth and adults: a population-level intervention with potential to reduce tobacco-related inequities. Cancer Causes Control 23:57–67. doi:10.1007/s10552-012-9902-4
Jamal A, King BA, Neff LJ et al (2016) Current cigarette smoking among adults—United States, 2005-2015. MMWR Morb Mortal Wkly Rep 65:1205–1211. doi:10.15585/mmwr.mm6544a2
Kowitt SD, Noar SM, Ranney LM, Goldstein AO (2017) Public attitudes toward larger cigarette pack warnings: results from a nationally representative U.S. sample. PLoS ONE 12:e0171496. doi:10.1371/journal.pone.0171496
Fallin A, Goodin AJ, King BA (2015) Menthol cigarette smoking among lesbian, gay, bisexual, and transgender adults. Am J Prev Med 48:93–97. doi:10.1016/j.amepre.2014.07.044
Fallin A, Goodin A, Lee YO, Bennett K (2015) Smoking characteristics among lesbian, gay, and bisexual adults. Prev Med 74:123–130. doi:10.1016/j.ypmed.2014.11.026
Burkhalter JE, Warren B, Shuk E et al (2009) Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers. Nicotine Tob Res 11:1312–1320. doi:10.1093/ntr/ntp140
Mahalik JR, Burns SM, Syzdek M (2007) Masculinity and perceived normative health behaviors as predictors of men’s health behaviors. Soc Sci Med 64:2201–2209
Thrasher JF, Arillo-Santillán E, Villalobos V et al (2012) Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content. Cancer Causes Control 23:69–80. doi:10.1007/s10552-012-9899-8
Mead EL, Cohen JE, Kennedy CE et al (2015) The role of theory-driven graphic warning labels in motivation to quit: a qualitative study on perceptions from low-income, urban smokers. BMC Public Health 15:92. doi:10.1186/s12889-015-1438-6
Fallin A, Neilands TB, Jordan JW et al (2015) Wreaking “havoc” on smoking. Am J Prev Med 48:S78–S85. doi:10.1016/j.amepre.2014.09.008
Fallin A, Neilands TB, Jordan JW, Ling PM (2015) Social branding to decrease lesbian, gay, bisexual, and transgender young adult smoking. Nicotine Tob Res 17:983–989. doi:10.1093/ntr/ntu265
Ling PM, Lee YO, Hong J et al (2014) Social branding to decrease smoking among young adults in bars. Am J Public Health 104:751–760. doi:10.2105/AJPH.2013.301666
Ortiz KS, Duncan DT, Blosnich JR et al (2015) Smoking among sexual minorities: are there racial differences? Nicotine Tob Res 17:1362–1368. doi:10.1093/ntr/ntv001
Factor R, Williams DR, Kawachi I (2013) Social resistance framework for understanding high-risk behavior among nondominant minorities: preliminary evidence. Am J Public Health 103:2245–2251. doi:10.2105/AJPH.2013.301212
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.
Conflict of interest
The authors declare that they have no conflicts of interest.
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.
Written informed consent was obtained from all individual participants included in the study.
About this article
Cite this article
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
- Tobacco cigarettes
- Graphic health warnings
- Perceived effectiveness
- Sexual and gender minorities
- Message testing
- United States