Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment

Abstract

Background: The U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups.

Methods/findings: Participants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057).

Conclusions: Findings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities.

Figure 1. FDA-approved pictorial warning label images.

This document includes images of the nine FDA-approved pictorial warning label images used in this study. Reprinted from http://www.fda.gov under a CC BY license, with permission from the FDA, copyright 2012.

Figure 2. Consort 2010 Flow Diagram.

This figure provides information on the study sample for assessment of eligibility (n = 5,359), the number excluded (n = 1,988) and randomized (n = 3,371), as well as the number allocated, followed up and analyzed for the experimental condition (n = 1,706) and control condition (n = 1,665).

Figure 3. Percentage indicating intention to quit by education level.

This figure shows the percentages reporting intention to quit in the next 30 days (yes/no) by exposure to the control or experimental condition for each level of education (high school or less/some college/college or more). In adjusted regression models, the interaction for experimental condition by education was marginally significant at p = .057. The figure indicates a stronger effect for the pictorial condition versus the text-only condition among individuals with moderate education compared with higher educated groups.