There is no doubt that health warnings have fulfilled their primary objective of informing consumers about the health risks of smoking. Health warnings that clearly inform consumers about the risks of smoking, even without changing the behaviour of a single person, are deemed effective in these terms. There has been considerable interest as to whether health warnings are also associated with changes in attitudes and behaviours associated with reduced levels of smoking.
The International Agency for Research on Cancer (IARC) discusses the difficulty of assessing the impact of health warnings in its comprehensive scientific handbook outlining appropriate methods for the evaluation of tobacco control policies. It emphasises the particular challenges with assessing the effectiveness of warnings in the context of multiple sources of influence in knowledge about health risks.1 According to the IARC, ‘there are serious problems in attributing changes in national-level trends to changes in health warnings, or any other individual policy measure’ (p314). It recommends instead, that governments implementing health warnings assess effectiveness by monitoring the following measures: noticeability, believability, attention to health risks, comprehension, intention to quit, use of cessation services and perceived helpfulness of warnings in quit attempts—refer Chapter 5.5 of the handbook.
Most of the early population research about the effectiveness of tobacco health warnings comes from studies of Australian warnings introduced in 1987 and 1995.2-5 These studies were followed by evaluations of the world’s first graphic warnings implemented in Canada in 2001,5-7 as well as studies which assessed the effects of Australia’s 2006 graphic warnings.8-16 Numerous studies have now been published assessing the effects of warnings in a variety of other countries. A comprehensive review of evidence published in Tobacco Control in 201117 identified 94 original articles on the topic of the effectiveness of health warnings, from countries including Canada, the US, Australia, the UK, the Netherlands, France, New Zealand, the Netherlands, Mexico, Brazil, Malaysia, China, Belgium, and Norway. Surveys comparing impacts of the introduction of different types of health warnings at different times in different countries 5, 8, 9, 18, 19 have been particularly valuable in establishing the effectiveness of warnings and the elements and characteristics of warnings20 likely to be most effective.
Several organisations and international research groups summarised the findings of this early research on health warnings including the comprehensive assessment of the impact of health warnings released by the International Tobacco Control Policy Evaluation Project (the ITC project) in 2009,21 the Sambrook Research Group summary of the evidence up to 2008,22 and the International Union Against Tuberculosis and Lung Disease and Tobacco Free Union summary of the evidence up to 2009.23
The evidence of the effectiveness of these warnings continues to grow. Since the Hammond review, a quantitative systematic review of evidence published on the effectiveness of strengthened health warnings on cigarette packs identified 32 studies published up to 2014, from 20 countries.24 Additional studies have been published from various countries including Germany,25 China,26 Australia,13, 14, 27, 28 the US,29-35 Canada,28, 35-37 Pakistan,38 Nigeria,39 Lebanon,40, 41 Uruguay,42 France, the UK and the Netherlands,18 Mexico,28 and developing Asian and European countries.43
This section extracts from the findings of this growing body of research to discuss what is known about the effectiveness of warnings where they have been implemented. Section 12A.4 outlines what is known about features of warnings believed to maximise their effectiveness. This includes a detailed discussion of the superiority of graphic over text-based warnings and the role of fear in prompting behaviour changes and the issue of unintended consequences. The results of studies assessing the impact of health warnings introduced in Australia in 2006 and 2012 are described more fully in Section 12A.5 and in Section 11A.9.
12A.3.1 Awareness of health warnings
As identified by Hammond,17 at least a dozen studies to December 2010 documented high levels of awareness for health warnings on tobacco packages.3, 7, 10, 44-52 Studies published since 2010 continue to show that introduction of stronger health warnings results in warnings being more frequently noticed and read.38, 42, 43, 53, 54
More smokers report getting information about the risks of smoking from health warnings than from any other source except TV in a majority of countries.17, 21 Health warnings are also a prominent source of health information for young non-smokers and the general public.10, 17, 47-50 Non-smokers have high level of recall for specific messages on packs.10, 49, 50
12A.3.2 Increase in knowledge about health effects
Overall, health warnings contribute to increased knowledge about health effects.55 High awareness of concepts covered in health warnings has been reported following introduction of warnings in Belgium56 and Europe.57 Awareness of smoking-related conditions covered in health warnings is higher than awareness of conditions not covered at the time by warnings.12, 37, 58 Smokers have greater knowledge about particular health effects in countries where those health effects are the subject of warnings than in countries where they are not.5, 21, 37, 59 Introduction of new or strengthened warnings has been shown to lead to increased knowledge of the subject matter contained in the warnings in Canada,60 in Australia,2, 3, 11-13, 16, 27 in the UK,5 and in France.61
12A.3.3 Increase in thoughts about quitting
Health warnings can invoke thoughts not just about the harms of smoking but also thoughts about quitting,27, 38, 42, 43, 62 and they occasionally lead to smokers forgoing cigarettes they would otherwise have smoked.27, 30, 38, 42, 63 Stronger warnings stimulate more of these reactions, including fear reactions.25, 27, 37 Negative emotions elicited by health warnings encourage behaviour change, promoting attention to warnings and behavioural responses that positively predict quit attempts.32, 34, 64-66
Some smokers also take steps to avoid stronger warnings, particularly for graphic rather than text warnings.8, 9, 19, 33, 67 Research shows that new warnings (strengthened either with increased size and/or use of graphics) have been more effective in stimulating targeted reactions than those they replaced. Some of this effect is due to novelty, but it is clear that objectively stronger messages persistently evoke greater levels of responses than weaker ones.
12A.3.4 Self-reported usefulness in quitting
Population surveys conducted after the introduction of large text or graphic health warnings suggest that they have been important in assisting smokers to try to smoke less or to try to quit. One-fifth of smokers reported such effects after introduction of enlarged text warnings in the EU from 2001.50 In countries such as Canada and Australia, even higher percentages of people report warnings as having prompted quitting behaviours. More than 40% of smokers in one Canadian survey reported that health warnings had motivated them to quit smoking.19 In response to a Government-sponsored survey in 2008,10 57% of Australian smokers reported that graphic health warnings (which started appearing on packs in Australia in mid-2006) had made them think about quitting and 34% reported them having helped them to try to quit. In a similar survey conducted in 2018, 52% of Australian smokers reported that the enhanced graphic health warnings introduced in 2012 made them think about quitting.27 A survey of 1500 smokers conducted in Pakistan in 201438 reported 32% of smokers attempted to quit following introduction of graphic health warnings in that country. In one study in the US,31 adding graphic health warnings to cigarette packs effectively increased quit attempts and success.
12A.3.5 Documented quit attempts
Research from Australia,4 Canada,63 and the ITC four-country (Australia, Canada, the US and UK) study9 show that responses to health warnings such as noticing cigarette warnings and forgoing cigarettes predict subsequent quitting attempts among individual smokers. The ITC study found strong evidence that health warnings stimulate such reactions that are predictable antecedents of quitting attempts. It concluded that the stronger the warnings, the greater the reactions, and thus the greater the quitting activity they evoke.9
12A.3.6 Effect on use of Quitlines
Introducing graphic cigarette packet warnings and a Quitline number on cigarette packets boosts demand for Quitline services with likely flow on effects to cessation. In the Netherlands, placement of the national Quitline number on packs with text-based warnings led to a marked increase in numbers of calls.68 Calls to the Quitline in Australia also increased after introduction of improved consumer product information in 2006, which included a requirement to list the Quitline number.15 And they increased again following the introduction of larger graphic warnings as part Australia’s plain packaging of cigarette packs in 2012.69 Similarly, after the New Zealand Quitline number was featured prominently on packets, awareness, and use of the service increased. 70-72
12A.3.7 Effects of health warnings on young people
A growing body of research has examined the effects of the introduction of health warnings on young people.10, 11, 39, 40, 48, 49, 73-77 These studies provide good evidence that health warnings on tobacco packaging have influenced young people’s attitudes, intentions, and smoking behaviour.10, 11, 39, 48, 49, 78, 79
In a national survey in the UK, 90% of youth non-smokers reported that warnings had ‘put them off smoking’.49 National representative surveys of more than 26,000 respondents from 27 EU member states and Norway found that three out of ten non-smokers reported that health warnings had been effective in discouraging them from smoking.50 Hammond notes17 that between one-fifth and two-thirds of youth non-smokers indicated that health warnings had helped prevent them from taking up smoking in Canada48 and Australia10—see Section 12A.5.1 for further details.
In Nigeria,39 544 students were interviewed on their perceptions of graphic warnings. The majority of students reacted to the images with fear and indicated that they believed that the images would prevent people from initiating smoking. One study 40 involving school and university students in Lebanon reported that graphic warnings positively impacted both students’ intentions not to start smoking, and intentions to quit. In the US 77 health warnings have also been found to lower adolescents’ intention to smoke in the future among those with a moderate lifetime smoking history (between 1 and 100 cigarettes) and increased intention to quit smoking among those with a heavy lifetime smoking history (more than 100 cigarettes).
12A.3.8 Effectiveness among low-income smokers and other sub-populations
A study conducted as part of the International Tobacco Control Policy Evaluation study examined (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings; and (iii) differences by demographic characteristics and smoking behaviour among smokers exposed to strengthened text warnings introduced in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006).18 The impact was highest among smokers of low socio-economic status. An EU survey also found that young people and manual workers were slightly more likely to perceive health warnings as effective.50 See Section 12A.4 for discussion about benefits of graphic warnings for those with limited levels of literacy.
Preliminary evidence suggests that countries with pictorial warnings demonstrate fewer disparities in health knowledge across educational levels.80 The findings of one important study 36 in Canada provides evidence that warning labels can improve treatment reach and reach equity within vulnerable populations. It assessed the impact of the introduction of warning labels with a quit line number, on selected vulnerable sub-populations. Treatment reach for the six-month period significantly improved compared to the same six-month period the year before. Warning labels improved reach equity for young males and those with an education level of high school or less.
12A.3.9 Evidence of wear-out of health warnings
Australian research shows that the peak levels of response to warnings is in the period immediately after their introduction onto packs,3 perhaps even before all packs on the market have the warnings.81 There is some decline in cognitive responses as consumers become used to seeing the images on the packs; warnings appear to lose some, but not all, of their impact with time.5, 8, 15, 27 For example, findings from Australia’s triennial National Drugs Strategy Household Survey has shown a steady decline in the proportion of smokers who report that health warnings helped motivate them to quit or cut down. In 2016, 8.5% of smokers mentioned health warnings as being a factor motivating their attempt to change their smoking behaviour, down from 11.1% in 2013, 15.2% in 2010, and 19.4% in 2007.82 Findings of a 2018 survey on the impact of the 2012 graphic health warnings reported that 54% of Australian smokers and recent quitters took more notice of the graphic health warnings when they first came out, indicative of wear out of these health warnings over time.27
Evidence presented to a Canadian Parliamentary committee in 2010 suggested that the effectiveness of the Canadian warnings declined by 30–60% over the seven years to 2009, and that new warning labels were urgently needed to strengthen their influence in helping smokers to quit and preventing new smokers from starting to smoke.83
This evidence is supported by findings of a study published on the consequences of not rotating health warnings in Canada and the US.35 The study analysed the wear out of health warnings in (i) the US over a period of nine years (2002–2011) where the same set of four small text warnings on the side of the pack have been in place since 1984, and (ii) Canada, where the same set of 16 pictorial warnings covered 50% of the pack from 2001 to 2012. There was significant wear out in both countries over the nine-year study period. Wear out was greater in Canada than in the US possibly because of the drop in the novelty effect of the Canadian warnings. The Canadian warnings had been introduced just prior to the study whereas the health warnings in the US had already been in place for 17 years at the start of the study period.
Another study analysed wear out of health warning labels among Australian adolescents aged 13-17.84 The study used surveys conducted over four time periods: (i) prior to health warning introduction (2005) (ii) after six months (2006), (iii) two years (2008) and five years (2011) post- health warning introduction. While cognitive responses to graphic health warnings in 2006 and 2008 increased from 2005, by 2011 cognitive responses had declined and returned to 2005 levels. These findings suggest that when novel, graphic health warning labels on cigarette packs increase cognitive responses among adolescents. However, this effect diminishes after five years, suggesting more regular message refreshment is needed.
Wear out could be influenced by the characteristics of the audience. Findings of a 2018 study on the predictors of health warnings message wear out in the US found that the level of message wear out differed across different audience segments.29 Current smokers reported greater message fatigue than transitioning smokers and nonsmokers. Persons who were younger, male, and had higher levels of education and income reported higher levels of message fatigue than other groups.
12A.3.10 Industry attempts to undermine the effectiveness of health warnings
In 2011, British American Tobacco International released a report claiming that health warnings have had little impact on sales of tobacco products in Australia and elsewhere.85 This report included an analysis relating introduction dates for health warnings to sales of cigarettes in each country. As explained by the International Agency for Research on Cancer1 immediate changes in behaviour as would be reflected in changes in smoking prevalence or sales are an unrealistic and inappropriate indicator of the effectiveness of health warnings.
Opposition to the introduction of improved health warnings by tobacco companies—and attempts to undermine their effectiveness once introduced—suggests that tobacco industry executives believe that warnings can contribute to population changes in the consumption of tobacco products.86 Despite the requirement for warnings to be rotated with equal frequency, some researchers believe that tobacco companies may be producing a higher proportion of packs using warnings perceived to be less disturbing, with a lower proportion of packs bearing the more hard-hitting warnings. Following the introduction of seven rotating graphic health warnings in New Zealand in 2008, researchers found that tobacco packs identified in a litter-collection study were more likely to carry one of the warnings rated less disturbing (such as a pregnant women with infant or damaged lungs) in preference to the more highly disturbing warnings (such as gangrenous toes, mouth cancer, and blindness).87
The effectiveness of health warning has also been undermined by promotional stickers88 and other design features on the packs89 which are visually distracting.
Several researchers have highlighted the potential of package design to undermine the impact of health warnings. This is one important rationale for calls for plain packaging of tobacco products—see InDepth 11A Packaging as promotion: Evidence for and effects of plain packaging for full details.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated July 2020)
References
1. International Agency for Research on Cancer. Methods for evaluating tobacco control policies Handbooks of Cancer Prevention, Tobacco Control, 12.Lyon, France: International Agency for Research on Cancer, 2009. Available from: https://www.iarc.fr/wp-content/uploads/2018/07/Tobacco_vol12.pdf.
2. Hill D. New cigarette-packet warnings: Are they getting through? Medical Journal of Australia, 1988; 148(9):478–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3362083?dopt=Abstract
3. Borland R and Hill D. Initial impact of the new Australian tobacco health warnings on knowledge and beliefs. Tobacco Control, 1997; 6(4):317–25. Available from: http://tc.bmjjournals.com/cgi/content/abstract/6/4/317
4. Borland R. Tobacco health warnings and smoking-related cognitions and behaviours. Addiction, 1997; 92(11):1427–35. Available from: https://doi.org/10.1111/j.1360-0443.1997.tb02864.x
5. Hammond D, Fong GT, McNeill A, Borland R, and Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: Findings from the international Tobacco control (ITC) four country survey. Tobacco Control, 2006; 15(suppl. 3):iii19–25. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii19
6. Martens D. Graphic tobacco warnings having desired effect. Canadian Medical Association Journal, 2002; 166(11):1453. Available from: http://www.cmaj.ca/cgi/content/full/166/11/1453
7. Hammond D, Fong GT, McDonald PW, Cameron R, and Brown KS. Impact of the graphic Canadian warning labels on adult smoking behaviour. Tobacco Control, 2003; 12(4):391–5. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/4/391
8. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, et al. Impact of graphic and text warnings on cigarette packs: Findings from four countries over five years. Tobacco Control, 2009; 18(5):358-64. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/5/358
9. Borland R, Yong H, Wilson N, Fong G, Hammond D, et al. How reactions to cigarette packet health warnings influence quitting: Findings from the ITC four-country survey. Addiction, 2009; 104(4):669-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19215595
10. Shanahan P and Elliott D. Evaluation of the effectiveness of the graphic health warnings on tobacco product packaging 2008. Canberra, Australia: Australian Government Department of Health and Ageing, 2009. Available from: http://webarchive.nla.gov.au/gov/20140801094931/http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-tobacco-eval-graphic-health-warnings-exec-sum.
11. White V, Webster B, and Wakefield M. Do graphic health warning labels have an impact on adolescents' smoking-related beliefs and behaviours? Addiction, 2008; 103(9):1562–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18783508
12. McCarthy M, Germain D, Brennan E, and Durkin S. Perceptions about the health effects of smoking and passive smoking among Victorian adults, 2003–2007. CBRC Research Paper Series no. 37 Melbourne: Centre for Behavioural Research in Cancer, The Cancer Council Victoria, August, 2007. Available from: https://www.cancervic.org.au/research/behavioural/research-papers/perceptions_smoking_cbrc_09.html.
13. Brennan E, Durkin SJ, Cotter T, Harper T, and Wakefield MA. Mass media campaigns designed to support new pictorial health warnings on cigarette packets: Evidence of a complementary relationship. Tobacco Control, 2011; 20(6):412-18. Available from: http://tobaccocontrol.bmj.com/content/early/2011/04/07/tc.2010.039321.abstract
14. Miller C, Hill D, Quester P, and Hiller J. Response of mass media, tobacco industry and smokers to the introduction of graphic cigarette pack warnings in Australia. European Journal of Public Health, 2009; 19(6):644-9. Available from: https://academic.oup.com/eurpub/article/19/6/644/518449
15. Miller C, Hill D, Quester P, and Hiller J. Impact on the Australian Quitline of new graphic cigarette pack warnings including the Quitline number. Tobacco Control, 2009; 18(3):235-7. Available from: http://tobaccocontrol.bmj.com/content/18/3/235.full
16. Miller C, Quester P, Hill D, and Hiller J. Smokers' recall of Australian graphic cigarette packet warnings and awareness of associated health effects, 2005-2008. BMC Public Health, 2011; 11(1):238. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-11-238.pdf
17. Hammond D. Health warning messages on tobacco products: A review. Tobacco Control, 2011; 20(5):327-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21606180
18. Hitchman S, Mons U, Nagelhout G, Guignard R, McNeill A, et al. Effectiveness of the European union text-only cigarette health warnings: Findings from four countries. European Journal of Public Health, 2011; [Epub ahead of print]. Available from: http://eurpub.oxfordjournals.org/content/early/2011/09/14/eurpub.ckr099.long
19. Hammond D, Fong G, Borland R, Cummings KM, McNeill A, et al. Text and graphic warnings on cigarette packages: Findings from the international tobacco control four country study. American Journal of Preventive Medicine, 2007; 32(3):202–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17296472
20. Fong GT, Hammond D, and Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bulletin of the World Health Organization, 2009; 87(8):640–3. Available from: http://www.who.int/bulletin/volumes/87/8/09-069575/en/index.html
21. International Tobacco Control Policy Evaluation Project. FCTC article 11 Tobacco warning labels: Evidence and recommendations from the ITC project. Buffalo, New York: Roswell Park Cancer Institute, 2009. Available from: https://www.itcproject.org/files/ITC_Tobacco_Labels_Bro_V3.pdf.
22. Sambrook Research International. A review of the science base to support the development of health warnings for tobacco packages. A report prepared for European commission, directorate general for health and consumers. Brussels: European Commission, 2009. Available from: http://ec.europa.eu/health/tobacco/docs/warnings_report_en.pdf.
23. Selin H. Tobacco packaging and labelling: Technical guide. International Union Against Tuberculosis and Lung Disease and Tobacco-Free Union, 2010. Available from: https://www.theunion.org/what-we-do/publications/technical/tobacco-packaging-and-labelling-technical-guide.
24. Noar SM, Francis DB, Bridges C, Sontag JM, Ribisl KM, et al. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Social Science & Medicine, 2016.
25. Schneider S, Gadinger M, and Fischer A. Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Education and Counseling, 2011; [Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21482060
26. Qin Y, Wu M, Pan X, Xiang Q, Huang J, et al. Reactions of Chinese adults to warning labels on cigarette packages: A survey in Jiangsu province. BMC Public Health, 2011; 11:133. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-11-133.pdf
27. Essence Communications. Evaluation of effectiveness of graphic health warnings on tobacco product packaging: An evaluation report. Prepared for the Department of Health, 2018. Available from: https://beta.health.gov.au/resources/publications/evaluation-of-effectiveness-of-graphic-health-warnings-on-tobacco-product-packaging.
28. Anshari D, Yong HH, Borland R, Hammond D, Swayampakala K, et al. Which type of tobacco product warning imagery is more effective and sustainable over time? A longitudinal assessment of smokers in Canada, Australia and Mexico. BMJ Open, 2018; 8(7):e021983. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30007932
29. So J and Popova L. A profile of individuals with anti-tobacco message fatigue. American Journal of Health Behavior, 2018; 42(1):109–18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29320344
30. Agaku IT, Singh T, Rolle IV, and Ayo-Yusuf OA. Exposure and response to current text-only smokeless tobacco health warnings among smokeless tobacco users aged >/=18years, United States, 2012-2013. Preventive Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26892913
31. Brewer NT, Hall MG, Noar SM, and et al. Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. JAMA Internal Medicine, 2016; 176(7):905–12. Available from: http://dx.doi.org/10.1001/jamainternmed.2016.2621
32. Evans A, Peters E, Strasser A, Emery L, Sheerin K, et al. Graphic warning labels elicit affective and thoughtful responses from smokers: Results of a randomized clinical trial. PLoS ONE, 2015; 10(12):e0142879. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26672982
33. Hall MG, Mendel JR, Noar SM, and Brewer NT. Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States. Social Science & Medicine, 2018; 213:165–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30096636
34. Hall MG, Sheeran P, Noar SM, Boynton MH, Ribisl KM, et al. Negative affect, message reactance and perceived risk: How do pictorial cigarette pack warnings change quit intentions? Tobacco Control, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29248897
35. Hitchman SC, Driezen P, Logel C, Hammond D, and Fong GT. Changes in effectiveness of cigarette health warnings over time in Canada and the United States, 2002-2011. Nicotine & Tobacco Research, 2014; 16(5):536–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24323572
36. Baskerville NB, Hayward L, Brown KS, Hammond D, Kennedy RD, et al. Impact of Canadian tobacco packaging policy on quitline reach and reach equity. Preventive Medicine, 2015; 81:243–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26400639
37. Dickson J. Graphic warnings and images on cigarettes are effective: Focus groups. CTV News, 2018. Available from: https://www.ctvnews.ca/health/graphic-warnings-and-images-on-cigarettes-are-effective-focus-groups-1.4022511
38. Ahsan M, Saad M, Jawed M, Akhtar S, Haseeb A, et al. Impact of tobacco health warnings on smokers in Pakistan. Journal Of Pakistan Medical Association, 2016; 66(1):59–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26712183
39. Adebiyi AO, Uchendu OC, Bamgboye E, Ibitoye O, and Omotola B. Perceived effectiveness of graphic health warnings as a deterrent for smoking initiation among adolescents in selected schools in southwest Nigeria. Tobacco Induced Diseases, 2016; 14:7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26997939
40. Alaouie H, Afifi RA, Haddad P, Mahfoud Z, and Nakkash R. Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students. Tobacco Control, 2015; 24(e1):e72–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25701880
41. Layoun N, Salameh P, Waked M, Aoun Bacha Z, Zeenny RM, et al. Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon. Patient Preference and Adherence, 2017; 11:331-42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28280306
42. Gravely S, Fong GT, Driezen P, McNally M, Thrasher JF, et al. The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: Longitudinal findings from the international Tobacco control (ITC) Uruguay survey. Tobacco Control, 2016; 25(1):89–95. Available from: http://tobaccocontrol.bmj.com/content/25/1/89.abstract
43. Caixeta RB, Blanco A, Fouad H, Khoury RN, Sinha DN, et al. Cigarette package health warnings and interest in quitting smoking–14 countries, 2008–2010. Morbidity and Mortality Weekly Report (MMWR), 2011; 60(20):645–51. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6020a2.htm
44. Cavalcante T. Labelling and packaging in Brazil. National Cancer Institute, Health Ministry of Brazil; World Health Organization, 2010. Available from: http://www.who.int/tobacco/training/success_stories/en/best_practices_brazil_labelling.pdf.
45. Fathelrahman A, Omar M, Awang R, Borland R, Fong G, et al. Smokers' responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine & Tobacco Research, 2009; 11(3):248-53. Available from: http://ntr.oxfordjournals.org/content/early/2009/01/01/ntr.ntn029.abstract
46. Elliott and Shanahan Research. Evaluation of the health warnings and explanatory health messages on tobacco products. Canberra: Tobacco and Alcohol Strategies Section, Department of Health and Aged Care, 2000. Available from: https://www.who.int/fctc/guidelines/ArtElevenCommonwealthEight.pdf.
47. Chaiton M, Cohen J, Kaiserman MJ, and Leatherdale ST. Ch 7. Beliefs and attitudes. Youth smoking survey-technical report. Health Canada, 2002. Ottawa: Health Canada, 2005. Available from: http://www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/yss-etj-2002/index-eng.php.
48. Environics Research Group Ltd. The health effects of tobacco and health warning messages on cigarette packages: Survey of youth: Wave12 surveys. Ottawa: Health Canada, 2007.
49. Moodie C, Mackintosh A, and Hammond D. Adolescents' response to text-only tobacco health warnings: Results from the 2008 UK youth Tobacco policy survey. European Journal of Public Health, 2009; 20(4):463-9. Available from: https://academic.oup.com/eurpub/article/20/4/463/635402
50. European Commission. Eurobarometer: Survey on tobacco (analytical report). 2009. Available from: http://ec.europa.eu/public_opinion/flash/fl_253_en.pdf
51. Environics Research Group Ltd. Health warnings testing: Final report. Ottawa: Prepared for Health Canada, 1999. Available from: http://legacy.library.ucsf.edu/tid/nql70g00.
52. Les E´tudes De Marche Createc. Quantitative study of Canadian youth smokers and vulnerable non-smokers: Effects of modified packaging through increasing the size of warnings on cigarette packages. Ottawa: Health Canada, 2008.
53. Majumdar A, Kumar SG, and Selvaraj R. Awareness of health warnings and factors predicting awareness and perceived effectiveness of pictorial health warnings on tobacco products among adults in rural Puducherry, India. Journal of Education and Health Promotion, 2017; 6:23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28584823
54. Bhardwaj V, Fotedar S, Abbot S, Jhingta P, Sharma D, et al. Awareness of pictorial warning on cigarette packets and its impact on smoking cessation among smokers in Shimla, Himachal Pradesh: A cross-sectional study. 2016; 5(3):148–53. Available from: http://www.ijhas.in/article.asp?issn=2278-344X;year=2016;volume=5;issue=3;spage=148;epage=153;aulast=Bhardwaj
55. Popova L, Thrul J, and Glantz SA. Effects of large cigarette warning labels on smokers' expected longevity. American Journal of Health Behavior, 2018; 42(2):85–92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29458517
56. IPSOS. Survey, Belgium. Effectiveness of picture warnings on behalf of the Belgium cancer foundation. cited in Sambrook Research International, 2007.
57. Devlin E, Anderson S, Hastings G, and MacFadyen L. Targeting smokers via tobacco product labelling: Opportunities and challenges for pan European health promotion. Health Promotion International, 2005; 20(1):41-9. Available from: https://academic.oup.com/heapro/article/20/1/41/797578
58. Ng D, Roxburgh S, Sanjay S, and Au Eong K. Awareness of smoking risks and attitudes towards graphic health warning labels on cigarette packs: A cross-cultural study of two populations in Singapore and Scotland. Eye, 2009; 24(5):864-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19696800?dopt=Citation
59. Thrasher J, Hammond D, Fong G, and Arillo-Santillán E. Smokers' reactions to cigarette package warnings with graphic imagery and with only text: A comparison between Mexico and Canada. Salud pública de México, 2007; 49(suppl. 2):S233-40.
60. Environics Research Group Ltd. The health effects of tobacco and health warning messages on cigarette packages: Survey of adults and adult smokers: Wave 9 surveys. Ottawa: Health Canada, 2005.
61. Fong G, Ratte S, and Craig L ea. E´valuation des politiques de lutte contre le tabagisme en France: Re´sultats de la premie`re vague de l’enqueˆte ITC France. Evaluating tobacco control policies in France: Results of the first wave of the ITC France survey. Bulletin e´pide´miologique hebdomadaire (nume´ro the´matiquedjourne´e mondiale sans tabac 2008. (Special IssuedWorld No Tobacco Day 2008). Weekly Epidemiological Bulletin, 2007; 22:183-7. Available from: https://www.researchgate.net/publication/255992574_Evaluation_des_politiques_de_lutte_contre_le_tabagisme_en_France_resultats_de_la_premiere_vague_de_l%27enquete_ITC_France
62. Ngoc Bich N, Thu Ngan T, Bao Giang K, Thi Hai P, Thi Thu Huyen D, et al. Salience and impact of health warning label on cigarette packs in Vietnam: Findings from the global adult Tobacco survey 2015. Behavioral Medicine, 2018:1–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29652628
63. Hammond D, Fong G, McDonald P, Brown K, and Cameron R. Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health, 2004; 94(8):1442–5. Available from: http://www.ajph.org/cgi/content/full/94/8/1442
64. Cho YJ, Thrasher JF, Yong HH, Szklo AS, O'Connor RJ, et al. Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Social Science & Medicine, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29096946
65. Droulers O, Gallopel-Morvan K, Lacoste-Badie S, and Lajante M. The influence of threatening visual warnings on tobacco packaging: Measuring the impact of threat level, image size, and type of pack through psychophysiological and self-report methods. PLoS ONE, 2017; 12(9):e0184415. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28910317
66. Grabmeier J. How graphic photos on cigarette packs help smokers consider quitting. Medical Xpress, 2015. Available from: http://medicalxpress.com/news/2015-12-graphic-photos-cigarette-smokers.html
67. Hunt E. Smokers distort health warnings on cigarette packs, research shows The Guardian, 2016. Available from: https://www.theguardian.com/australia-news/2016/jun/03/smokers-distort-health-warnings-on-cigarette-packs-research-shows
68. Willemsen MC, Simons C, and Zeeman G. Impact of the new EU health warnings on the Dutch quit line. Tobacco Control, 2002; 11(4):381–2. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/11/4/381
69. Young JM, Stacey I, Dobbins TA, Dunlop S, Dessaix AL, et al. Association between tobacco plain packaging and Quitline calls: A population-based, interrupted time-series analysis. Medical Journal of Australia, 2014; 200(1):29-32. Available from: https://www.mja.com.au/journal/2014/200/1/association-between-tobacco-plain-packaging-and-quitline-calls-population-based
70. Wilson N, Weerasekera D, Hoek J, Li J, and Edwards R. Increased smoker recognition of a national quitline number following introduction of improved pack warnings: ITC project New Zealand. Nicotine & Tobacco Research, 2010; 12(suppl.):S72–7. Available from: http://ntr.oxfordjournals.org/content/12/suppl_1/S72.long
71. Li J and Grigg M. New Zealand: New graphic warnings encourage registrations with the quitline. Tobacco Control, 2009; 18(1):72. Available from: http://tobaccocontrol.bmj.com/content/18/1/72.full?sid=1283a803-1cbe-4db3-9956-ee41b10ae647
72. Wilson N, Li J, Hoek J, Edwards R, and Peace J. Long-term benefit of increasing the prominence of a quitline number on cigarette packaging: 3 years of Quitline call data. New Zealand Medical Journal, 2010; 123(1321):109-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20927170
73. Robinson T and Killen J. Do cigarette warning labels reduce smoking? Paradoxical effects among adolescents. Archives of Pediatrics & Adolescent Medicine, 1997; 151(3):267-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9080935
74. Ho R. Cigarette advertising and cigarette health warnings: What role do adolescents' motives for smoking play in their assessment? Australian Psychologist, 1994; 29(1):49-56. Available from: http://onlinelibrary.wiley.com/doi/10.1080/00050069408257321/abstract
75. O'Hegarty M, Pedersen L, Nelson D, Mowery P, Gable J, et al. Reactions of young adult smokers to warning labels on cigarette packages. American Journal of Preventative Medicine, 2006; 30(6):467–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16704939
76. Peterson E, Thomsen S, Lindsay G, and John K. Adolescents' attention to traditional and graphic tobacco warning labels: An eye-tracking approach. Journal of Drug Education, 2010; 40(3):227–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21313984
77. Blanton H, Snyder LB, Strauts E, and Larson JG. Effect of graphic cigarette warnings on smoking intentions in young adults. PLoS ONE, 2014; 9(5):e96315. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24806481
78. Goodall C and Appiah O. Adolescents' perceptions of Canadian cigarette package warning labels: Investigating the effects of message framing. Health Communication, 2008; 23(2):117–27. Available from: http://www.informaworld.com/smpp/content?content=10.1080/10410230801967825
79. Sabbane LI, Lowrey TM, and Chebat J-C. The effectiveness of cigarette warning label threats on nonsmoking adolescents. Journal of Consumer Affairs, 2009; 43(2):332–45. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1745-6606.2009.01142.x/abstract
80. Siahpush M, McNeill A, Hammond D, and Fong GT. Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 international Tobacco control (ITC) four country survey. Tobacco Control, 2006; 15(suppl. 3):iii65-70. Available from: http://tobaccocontrol.bmj.com/content/15/suppl_3/iii65.abstract
81. Trotter L. Tobacco health warnings: Longitudinal evaluation effects on recall and smoking related behaviours, in Quit evaluation studies no. 9. The Anti-Cancer Council of Victoria; 1998. p 133-42.
82. Australian Institute of Health and Welfare. National Drug Strategy Household Survey (NDSHS) 2016 key findings data tables. Canberra: AIHW, 2017. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/2016-ndshs-detailed/data.
83. McEwen K. ITC evidence of Canadian warning label wear-out presented to policymakers. International Tobacco Control Policy Evaluation Project, 2010. Last update: Viewed December.
84. White V, Bariola E, Faulkner A, Coomber K, and Wakefield M. Graphic health warnings on cigarette packs: How long before the effects on adolescents wear out? Nicotine & Tobacco Research, 2015; 17(7):776–83. Available from: http://ntr.oxfordjournals.org/content/early/2014/09/25/ntr.ntu184.abstract
85. Deloitte. Tobacco packaging regulation: An international assessment of the intended and unintended consequences. London 2011. Available from: http://www.indiaenvironmentportal.org.in/content/328272/tobacco-packaging-regulation-an-international-assessment-of-the-intended-and-unintended-consequences/.
86. Chapman S and Carter SM. 'Avoid health warnings on all tobacco products for just as long as we can': A history of Australian tobacco industry efforts to avoid, delay and dilute health warnings on cigarettes. Tobacco Control, 2003; 12(suppl. 3):iii13–22. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/suppl_3/iii13
87. Wilson N. Smokers respond to pictorial health warnings. Science, 2011; 333(6044):822. Available from: http://www.sciencemag.org/content/333/6044/822.1.short
88. Mir H, Buchanan D, Gilmore A, McKee M, Yusuf S, et al. Cigarette pack labelling in 12 countries at different levels of economic development. Journal of Public Health Policy, 2011; 32(2):146-64. Available from: http://www.palgrave-journals.com/jphp/journal/vaop/ncurrent/full/jphp20113a.html
89. Rommel C. The final warnings. World Tobacco, 2006; (203):2.
Recent references
Cameron, L.D., J.K. Pepper, and N.T. Brewer, Responses of young adults to graphic warning labels for cigarette packages. Tobacco Control, 2013.Available from: http://tobaccocontrol.bmj.com/content/early/2013/04/25/tobaccocontrol-2012-050645.abstract
Thomson, G., Wilson, N., and Maubach, N., Switch to large pictorial health warnings on cigarette packs. BMJ, 2013. 346: p. f2084. Available from: http://www.bmj.com/content/346/bmj.f2084.pdf%2Bhtml
http://www.ncbi.nlm.nih.gov/pubmed/23575927
University of Granada, Warning images for cigarette packs do not make a strong enough emotional impact, in MedicalXPress 2013.Available from: http://medicalxpress.com/news/2013-05-images-cigarette-strong-emotional-impact.html
Report of efficacy of new warnings proposed for EU
http://medicalxpress.com/news/2013-05-images-cigarette-strong-emotional-impact.html
Timea Reka Partos, Ron Borland, Hua-H Yong, James Thrasher, David Hammond. Cigarette packet warning labels can prevent relapse: findings from the International Tobacco Control 4-Country policy evaluation cohort study. Tob Control 2013; 22 e43-e50
http://tobaccocontrol.bmj.com/content/early/2012/11/25/tobaccocontrol-2012-050598
James F Thrasher, Nandita Murukutla, Rosaura Perez-Hernandez, Jorge Alday, Edna Arillo-Santillan, Claudia Cedillo, Juan Pablo Gutierrez. Linking mass media campaigns to pictorial warning labels on cigarette packages: a cross-sectional study to evaluate effects among Mexican smokers. Tob Control 2013; 22 e57-e65 http://tobaccocontrol.bmj.com/cgi/content/abstract/22/e1/e51?etoc