Journal of Behavioral Medicine

, Volume 41, Issue 3, pp 398–405 | Cite as

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

  • Marissa G. HallEmail author
  • Theresa M. Marteau
  • Cass R. Sunstein
  • Kurt M. Ribisl
  • Seth M. Noar
  • Elizabeth N. Orlan
  • Noel T. Brewer



Understanding factors that influence public support for “nudging” policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers’ support for requiring pictorial warnings on cigarette packs.


In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US.


Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001).


Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.


Public support Policy support Graphic warnings Pictorial warnings Tobacco control Reactance Nudging 



Research reported in this publication was supported by The National Cancer Institute and FDA Center for Tobacco Products (CTP) under Award Number P30CA016086-38S2. F31CA196037 and T32-CA057726 from the National Cancer Institute of the National Institutes of Health supported MGH’s time writing the paper. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

Compliance with ethical standards

Conflict of interest

Kurt M. Ribisl and Noel T. Brewer have served as paid expert consultants in litigation against the tobacco industry. Cass R. Sunstein helped oversee federal regulation in the US government between 2009 and 2012, and he worked on the topic of graphic health warnings. Marissa G. Hall, Theresa Marteau, Seth M. Noar and Elizabeth N. Orlan declare that they have no conflict of interest.

Human and animal rights and Informed consent

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

Supplementary material

10865_2018_9910_MOESM1_ESM.pdf (153 kb)
Supplementary material 1 (PDF 153 kb)
10865_2018_9910_MOESM2_ESM.pdf (35 kb)
Supplementary material 2 (PDF 35 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Marissa G. Hall
    • 1
    Email author
  • Theresa M. Marteau
    • 2
  • Cass R. Sunstein
    • 3
  • Kurt M. Ribisl
    • 1
    • 4
  • Seth M. Noar
    • 1
    • 5
  • Elizabeth N. Orlan
    • 4
  • Noel T. Brewer
    • 4
  1. 1.Lineberger Comprehensive Cancer CenterUniversity of North CarolinaChapel HillUSA
  2. 2.Behaviour and Health Research Unit, Institute of Public HealthUniversity of CambridgeCambridgeUK
  3. 3.Harvard Law SchoolHarvard UniversityCambridgeUSA
  4. 4.Department of Health Behavior, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.School of Media and JournalismUniversity of North CarolinaChapel HillUSA

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