Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study

Abstract

Background: Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the United States. The current study examined the effectiveness of health warnings on cigarette packages in four countries.

Methods: Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (n=14,975): Canada (n=3687), United States (n=4273), UK (n=3634), and Australia (n=3381). Surveys were conducted between 2002 and 2005, before and at three time points following implementation of new package warnings in the UK.

Results: At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave.

Conclusions: Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.

Figure 1

Health warnings in the ITC Four-Country Survey: 2002–2005 Note: the new UK warnings include one of two warnings on the front (“Smoking Kills” or “Smoking seriously harms you and others around you”), and one of 14 rotating warnings on the back of the package. ITC, International Tobacco Control

Figure 2

Sample size and follow-up rates for the ITC Four-Country Survey: Waves 1–4 ITC, International Tobacco Control

Figure 3

Responses to cigarette health warnings between 2002 and 2005 (n =14,975)* ^{† †} The vertical dotted line indicates the implementation date of the new health warnings in the UK. *The Wave 1 data from Canada and Wave 4 data from the UK have been highlighted to indicate 2.5 year post-implementation dates in each country.

Figure 4

Countries with picture-based health warnings *A set of pictorial warnings has been created for European Union members; however, each member can decide whether or not to adopt the pictorial warnings in place of the mandatory text-based warnings.