Cancer Causes & Control

, Volume 23, Supplement 1, pp 69–80 | Cite as

Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content

  • James F. ThrasherEmail author
  • Edna Arillo-Santillán
  • Victor Villalobos
  • Rosaura Pérez-Hernández
  • David Hammond
  • Jarvis Carter
  • Ernesto Sebrié
  • Raul Sansores
  • Justino Regalado-Piñeda
Original paper



The objective of this study was to determine the most effective content of pictorial health warning labels (HWLs) and whether educational attainment moderates these effects.


Field experiments were conducted with 529 adult smokers and 530 young adults (258 nonsmokers; 271 smokers). Participants reported responses to different pictorial HWLs printed on cigarette packages. One experiment involved manipulating textual form (testimonial narrative vs. didactic) and the other involved manipulating image type (diseased organs vs. human suffering).


Tests of mean ratings and rankings indicated that pictorial HWLs with didactic textual forms had equivalent or significantly higher credibility, relevance, and impact than pictorial HWLs with testimonial forms. Results from mixed-effects models confirmed these results. However, responses differed by participant educational attainment: didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In the second experiment, with textual content held constant, greater credibility, relevance, and impact was found for graphic imagery of diseased organs than imagery of human suffering.


Pictorial HWLs with didactic textual forms seem to work better than those with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.


Product labeling Health communication Tobacco Health policy 



Funding for data collection and analysis on this study came from the Union against Tuberculosis and Lung Disease (Mexico 7-1), with additional support for analysis coming from CONACyT (Convocatoria Salud-2007-C01-70032) and the US National Cancer Institute (P01 CA138389). Dr Ernesto Sebrié was supported by the Flight Attendant Medical Research Institute (FAMRI).


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Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • James F. Thrasher
    • 1
    • 2
    Email author
  • Edna Arillo-Santillán
    • 2
  • Victor Villalobos
    • 3
  • Rosaura Pérez-Hernández
    • 2
  • David Hammond
    • 4
  • Jarvis Carter
    • 1
  • Ernesto Sebrié
    • 5
  • Raul Sansores
    • 6
  • Justino Regalado-Piñeda
    • 7
  1. 1.Department of Health Promotion, Education and Behavior, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  2. 2.Centro de Investigación en Salud PoblacionalInstituto Nacional de Salud PúblicaCuernavacaMexico
  3. 3.School of Public HealthUniversity of CaliforniaBerkeleyUSA
  4. 4.School of Public Health & Health SystemsUniversity of WaterlooWaterlooCanada
  5. 5.Department of Health BehaviorRoswell Park Cancer InstituteBuffaloUSA
  6. 6.Instituto Nacional de Enfermedades RespiratoriasMexico CityMexico
  7. 7.Consejo Nacional contra Adicciones, Secretaría de SaludMexico CityMexico

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