Which Tobacco Product Warning Imagery is Most Effective? A Longitudinal Assessment of Smokers in Australia, Canada, and Mexico

BACKGROUND: This study examined temporal changes in smokers’ responses to pictorial health warning (PHW) with different types of imagery (i.e., symbolic representations of risk; personal suffering from smoking; graphic depictions of bodily harm) on cigarette packs under natural conditions of exposure.
METHODS: Adult smokers from online panels in Australia (AU; n=4,006), Canada (CA; n=4,002) and Mexico (MX; n=4,006) were surveyed quarterly after new PHWs were implemented in each country. Participants were shown specific PHWs on packs in their country and asked about: negative emotions (i.e., fear; disgust; worry about smoking risks); PHW believability; attention to the PHW in the prior month; interpersonal communication about the PHW in the prior month; and motivation to quit because of the PHW. Temporal changes and differences by imagery type were analyzed using country-specific generalized estimating equations models.
RESULTS: Across countries, assessment of the main effects of time on PHW responses indicated no changes over time except for increasing attention to PHWs in CA (OR=1.17, p CONCLUSIONS: PHWs with diverse graphic and suffering imagery appear effective in inhibiting wear out for different key pathways of PHW effects.