Potential Effectiveness of Pictorial Warning Labels That Feature the Images and Personal Details of Real People

Abstract

Introduction: Pictorial warning labels (PWL) that use photographs and the personal details of real people whose health has been affected by smoking (testimonial PWL) provide factual information about the consequences of tobacco use.

Methods: Nine hundred and twenty-four adult current smokers participated in an online experiment that tested responses to four types of warning labels: (1) non-testimonial text warning labels (currently on packs in the United States); (2) non-testimonial PWL (previously proposed by the United States Food and Drug Administration); (3) image only testimonial PWL (created for study); (4) image + personal details testimonial PWL (created for study). Participants were randomly assigned to condition and then exposed to up to five warning labels addressing different health effects. Differences between conditions were assessed using emotional responses and a set of intention measures immediately following exposure, and self-reported behavior change at 5-week follow-up.

Results: Compared to the non-testimonial text warning labels, all PWL elicited stronger emotional responses and intentions to forgo cigarettes and avoid the warning labels. Non-testimonial PWL and image + personal details testimonial PWL elicited stronger intentions to quit, whereas image only testimonial PWL generated a greater amount of quitting activity in the weeks following exposure. There were no significant differences in responses when comparing the non-testimonial PWL with both types of testimonial PWL.

Conclusions: PWL that use images of real people convey factual information about the health effects of tobacco use. These testimonial PWL may be a promising alternative to the images previously proposed for use on PWL in the United States.

Implications: In the United States, the PWL developed by the Food and Drug Administration (FDA) in 2011 were found by the courts to be unconstitutional, in part because they were deemed to present an opinion rather than fact. Findings from this experimental study indicate that PWL that use the images and personal details of real people to convey factual information about the health effects of tobacco use may satisfy the FDA's requirement for a set of PWL that (1) have the potential to positively impact the determinants of smoking cessation behavior, (2) meet legislative requirements under the Family Smoking Prevention and Tobacco Control Act and (3) may be more acceptable to the courts than the previously proposed and now dismissed PWL that carried non-factual images.

Figure 1.

Study procedure. ^{^}For participants in the non-testimonial TWL condition, the first three warning labels were selected from a pool of four warning labels (and so the fourth label was the final one remaining). For participants in the non-testimonial PWL and testimonial PWL conditions, the first three warning labels were selected from a pool of five warning labels (Table 1). ⁺Additional outcomes measured following Dose 1 included intentions to seek help when trying to quit (ie, intentions to call a quitline, buy a nicotine replacement product, enrol in a smoking cessation program), unprompted and prompted knowledge of the health effects of smoking, attitudes towards smoking, and self-efficacy to quit. ⁺⁺Additional outcomes measured following Dose 2 and Dose 3 included engagement with the warning labels, identification with the person shown in the warning label, defensive processing, and perceived effectiveness of the warning labels. Digital images of the warning labels and cigarette packs were created by Kyle Cassidy, Annenberg School for Communication, University of Pennsylvania.