Text and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study

Hammond, David; Fong, Geoffrey T.; Borland, Ron; Cummings, K. Michael; McNeill, Ann; Driezen, Pete

doi:10.1016/j.amepre.2006.11.011

« Previous Next »American Journal of Preventive Medicine
Volume 32, Issue 3 , Pages 202-209, March 2007

Text and Graphic Warnings on Cigarette Packages:

Findings from the International Tobacco Control Four Country Study

David Hammond, PhD
- Department of Health Studies & Gerontology, University of Waterloo, Waterloo, Ontario
- Address correspondence and reprint requests to: David Hammond, Department of Health Studies & Gerontology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.
Geoffrey T. Fong, PhD
- Department of Psychology, University of Waterloo, Waterloo, Ontario
Ron Borland, PhD
- The Cancer Council Victoria, Melbourne, Australia
K. Michael Cummings, PhD
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York
Ann McNeill, PhD
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham, London, UK
Pete Driezen, MSc
- Department of Health Studies & Gerontology, University of Waterloo, Waterloo, Ontario

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.