Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption

  • Daniel Romer
  • Stuart G. Ferguson
  • Andrew A. Strasser
  • Abigail T. Evans
  • Mary Kate Tompkins
  • Joseph Macisco
  • Michael Fardal
  • Martin Tusler
  • Ellen Peters
Original Article

Abstract

Background

Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit.

Purpose

Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings.

Methods

Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking.

Results

Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy.

Conclusions

Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.

Keywords

Warning labels Emotion Smoking Self-efficacy Smoking satisfaction 

Supplementary material

12160_2017_9916_MOESM1_ESM.docx (267 kb)
ESM 1(DOCX 267 kb)

References

  1. 1.
    R. J. Reynolds Co. v. Food and Drug Administration. D. C. Circuit Court of Appeals, 696 F.3d 1205, 2012.Google Scholar
  2. 2.
    Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: Findings from the international tobacco control four country study. Am J Prev Med. 2007; 32:202–9.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Magnan RE, Cameron LD. Do young adults perceive that cigarette graphic warnings provide knowledge about the harms of smoking? Ann Behav Med. 2015; 49(4):594-604.Google Scholar
  4. 4.
    Azagba S, Sharaf MF. The effect of graphic cigarette warning labels on smoking behavior: Evidence from the Canadian experience. Nicotine Tob Res. 2013; 15(3):708–17.CrossRefPubMedGoogle Scholar
  5. 5.
    Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob Control. 2016; 25:341-354.Google Scholar
  6. 6.
    Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach LE, et al. Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. Arch Intern Med. 2016; 176(7):905–12.Google Scholar
  7. 7.
    Evans AT, Peters E, Strasser AA, Emery LF, Sheerin KM, Romer D. Graphic warning labels elicit affective and thoughtful responses from smokers: Results of a randomized clinical trial. Plos One. 2015; 10(12):1–23.Google Scholar
  8. 8.
    Schüz N, Ferguson SA. An exploratory examination of the mechanisms through which prequit patch use aids smoking cessation. Psychopharmacology (Berl). 2014; 231(13):2603–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Peters GY, Ruiter RAC, Kok G. Threatening communication: A critical re-analysis and a revised meta-analytic test of fear appeal theory. Health Psychol Rev. 2013; 7(Sup 1):S8–31.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Witte K, Allen M. A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Educ Behav. 2000; 27(5):591–615.CrossRefPubMedGoogle Scholar
  11. 11.
    Kessels LTE, Ruiter RAC, Jansma BM. Increased attention but not more efficient disengagement: Neuroscientific evidence for defensive processsing of health information. Health Psychol. 2010; 29(4):346–54.CrossRefPubMedGoogle Scholar
  12. 12.
    Ruiter RAC, Kok G. Saying is not (always) doing: Cigarette warning labels are useless. Eur J Public Health. 2005; 15(3):329.CrossRefGoogle Scholar
  13. 13.
    Romer D, Peters E, Strasser AA, Langleben DD. Desire versus efficacy in smokers’ paradoxical reactions to pictorial health warnings for cigarettes. Plos One. 2013; 8(1):e54937.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Koob G, Le Moal M. Drug addiction, dysregulation of reward ad allostasis. Neuropsychopharmacology. 2001; 24:97–129.CrossRefPubMedGoogle Scholar
  15. 15.
    Dolcos F, LaBar KS, Cabeza R. Remembering one year later: Role of the amydala and the medial temporal lobe memory system in retrieving emotional memories. Proc Natl Acad Sci. 2005; 102(7):2626–31.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Wang AL, Lowen SB, Romer D, Giorno M, Langleben DD. Emotional reaction facilitates the brain and behavioural impact of graphic cigarette warning labels in smokers. Tob Control. 2015; 24:225–32.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Strasser AA, Tang KZ, Sanborn PM, Zhou JY, Koslowski LT. Behavioral filter vent blocking on the first cigarette of the day predicts which smokers of light cigarettes will increase smoke exposure from blocked vents. Exp Clin Psychopharmacol. 2013; 17(6):405.CrossRefGoogle Scholar
  18. 18.
    Schüz N, Cianchi J, Shiffman S, Ferguson SG. Novel technologies to study smoking behavior: Current developments in ecological momentary assessment. Curr Addict Rep. 2015; 2:8–14.CrossRefGoogle Scholar
  19. 19.
    FDA. Required warnings for cigarette packages and advertisements. US Government, Fed. Reg. 36,628; 2011.Google Scholar
  20. 20.
    Heatherton TF, Koslowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom test for nicotine dependence: A revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991; 86(9):1119–27.CrossRefPubMedGoogle Scholar
  21. 21.
    Peters E, Romer D, Slovic P, Jamieson KH, Wharfield L, Mertz CK, et al. The impact and acceptability of Canadian-style cigarette warning labels among U.S. smokers and nonsmokers. Nicotine Tob Res. 2007; 9:473–81.CrossRefPubMedGoogle Scholar
  22. 22.
    Emery LF, Romer D, Sheerin KM, Jamieson KH, Peters E. Affective and cognitive mediators of the impact of cigarette warning labels. Nicotine Tob Res. 2014; 16(3):263–9.CrossRefPubMedGoogle Scholar
  23. 23.
    StataCorp. Stata Statistical Software: Release 13. College Station: StataCorp LP; 2013.Google Scholar
  24. 24.
    Muthen LK, Muthen BO. Mplus User’s Guide (Seventh Edition). Los Angeles: Muthen & Muthen; 2012.Google Scholar
  25. 25.
    MacKinnon DP, Lockwood CM, Williams J. Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivar Behav Res. 2004; 39(1):99–128.CrossRefGoogle Scholar
  26. 26.
    Enders CK. Applied Missing Data Analysis. New York: Guilford Press; 2010.Google Scholar
  27. 27.
    Peters E, Lipkus I, Diefenbach MA. The functions of affect in health communications and in the construction of health preferences. J Commun. 2006; 56(s1):S140–62.CrossRefGoogle Scholar
  28. 28.
    Klemperer EM, Hughes JR. Does the magnitude of reduction in cigarettes per day predict smoking cessation? A qualitative review. Nicotine Tob Res. 2016; 18(1):88-92.Google Scholar
  29. 29.
    Popova L. The extended parallel process model: Illuminating the gaps in research. Health Educ Behav. 2012; 39(4):455–73.CrossRefPubMedGoogle Scholar
  30. 30.
    Tannenbaum MB, Hepler J, Zimmerman RS, Saul L, Jacobs S, Wilson K, et al. Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychol Bull. 2016; 141(6):1178–204.CrossRefGoogle Scholar
  31. 31.
    Jamal A, Homa DM, O’Connor E, et al. Current cigarette smoking among adults—United States, 2005–2014. MMWR. 2015; 64(44):1233–1240.PubMedGoogle Scholar
  32. 32.
    Gwaltney CJ, Metrik J, Kahler CW, Shiffman S. Self-efficacy and smoking cessation: A meta-analysis. Psychol Addict Behav. 2009; 23(1):56–66.CrossRefPubMedGoogle Scholar
  33. 33.
    Hammond D, Reid JL, Driezen P, Boudreau C. Pictorial health warnings on cigarette packs in the United States: An experimental evaluation of the proposed FDA warnings. Nicotine Tob Res. 2013; 15(1):93–102.CrossRefPubMedGoogle Scholar
  34. 34.
    Levy DT, Mays D, Yuan Z, Hammond D, Thrasher JF. Public health benefits from pictorial health warnings on US cigarette packs: A SimSmoke simulation. Tob Control. 2017; doi:10.1136/tobaccocontrol-2016-053087.
  35. 35.
    Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 2008; 4:3.1–3.32.CrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2017

Authors and Affiliations

  • Daniel Romer
    • 1
  • Stuart G. Ferguson
    • 2
  • Andrew A. Strasser
    • 3
  • Abigail T. Evans
    • 4
  • Mary Kate Tompkins
    • 4
  • Joseph Macisco
    • 4
  • Michael Fardal
    • 4
  • Martin Tusler
    • 4
  • Ellen Peters
    • 4
  1. 1.Annenberg Public Policy CenterUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.School of MedicineUniversity of TasmaniaHobartAustralia
  3. 3.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of PsychologyThe Ohio State UniversityColumbusUSA

Personalised recommendations