Text and Graphic Warnings on Cigarette Packages

Findings from the International Tobacco Control Four Country Study


      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.


      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.


      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.


      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Murray C.J.
        • Lopez A.D.
        Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study.
        Lancet. 1997; 349: 1498-1504
      1. World Health Organization. Tobacco Free Initiative. Information on global tobacco use. Available at:

        • World Health Organization
        WHO Framework Convention on Tobacco Control. 2005 (Geneva, Switzerland. Available at:
        • Fischer P.M.
        • Richards E.J.B.
        • Krugman D.M.
        Recall and eye tracking study of adolescents viewing tobacco advertisements.
        JAMA. 1989; 261: 84-89
        • Crawford M.A.
        • Balch G.I.
        • Mermelstein R.
        • Tobacco Control Network Writing Group
        Responses to tobacco control policies among youth.
        Tob Control. 2002; 11: 14-19
        • Borland R.
        Tobacco health warnings and smoking-related cognitions and behaviours.
        Addiction. 1997; 92: 1427-1435
        • Willemsen M.C.
        The new EU cigarette health warnings benefit smokers who want to quit the habit: results from the Dutch Continuous Survey of Smoking Habits.
        Eur J Public Health. 2005; 15: 389-392
      2. Tandemar Research P. f. H. C. Cigarette packaging study: the evaluation of new health warning messages. Ottawa: Health Canada, 1996 (report TR#663022).

        • Borland R.
        • Hill D.
        Initial impact of the new Australian tobacco health warnings on knowledge and beliefs.
        Tob Control. 1997; 6: 317-325
        • Hammond D.
        • Fong G.T.
        • Borland R.
        • McNeill A.
        • Cummings K.M.
        • Hastings G.
        Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey.
        Tob Control. 2006; 15: iii19-iii25
        • Hammond D.
        • Fong G.T.
        • McDonald P.W.
        • Cameron R.
        • Brown K.S.
        The impact of the graphic Canadian warning labels on adult smokers.
        Tob Control. 2003; 12: 391-395
        • Hammond D.
        • Fong G.T.
        • McDonald P.W.
        • Brown K.S.
        • Cameron R.
        Graphic cigarette package warning labels do not lead to adverse outcomes: evidence from Canadian smokers.
        Am J Public Health. 2004; 94: 1442-1445
        • O’Hegarty M.
        • Pederson L.
        • Nelson D.
        • Mowery P.
        • Gable J.
        • Wortley P.
        Reactions of young adult smokers to warning labels on cigarette packages.
        Am J Prev Med. 2006; 30: 467-473
        • Koval J.
        • Aubur J.
        • Pederson L.
        • O’Hegarty M.
        • Chan S.
        The potential effectiveness of warning labels on cigarette packages: the perceptions of young adult Canadians.
        Can J Public Health. 2005; 96: 353-356
        • Henderson B.
        Wear out: an empirical investigation of advertising wear-in and wear-out.
        J Advert Res. 2000; 6: 95-100
        • Bornstein R.F.
        Exposure and affect: overview and meta-analysis of research.
        Psychol Bull. 1989; 106: 265-289
        • Health Canada
        Health Warning Testing: Final Report. Health Canada, Ottawa1999 (Prepared by Environics Research Group)
        • Strahan E.J.
        • White K.
        • Fong G.T.
        • Fabrigar L.R.
        • Zanna M.P.
        • Cameron R.
        Enhancing the effectiveness of tobacco package warning labels: a social psychological perspective.
        Tob Control. 2002; 11 (review): 183-190
      3. Directive 2001/37/EC of the European Parliament and of the Council of 5 June 2001 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco products. Official Journal of the European Communities, 18.7.2001. Available at:

        • Binson D.
        • Canchola J.A.
        • Catania J.A.
        Random selection in a national telephone survey: a comparison of the Kish, next-birthday, and last-birthday methods.
        J Off Stat. 2000; 16: 53-60
        • Singer E.
        • van Hoewyk J.
        • Maher M.P.
        Experiments with incentives in telephone surveys.
        Public Opin Q. 2000; 64: 171-188
        • Thompson M.E.
        • Fong G.T.
        • Hammond D.
        • et al.
        The methodology of the International Tobacco Control Policy Evaluation (Four-Country) Survey (ITCPES).
        Tob Control. 2006; 15: iii12-iii18
        • Heatherton T.F.
        • Koslowski L.T.
        • Frecker R.C.
        • Rickert W.S.
        • Robinson J.
        Measuring the heaviness of smoking using self-reported time to the first cigarette of the day and number of cigarettes smoked per day.
        Br J Addict. 1989; 84: 791-800
        • Health Canada
        The Health Effects of Tobacco and Health Warning Messages on Cigarette Packages—Survey of Adults and Adult Smokers: Wave 9 Surveys. Health Canada, Ottawa2005 (Prepared by Environics Research Group. January)
        • Commonwealth of Australia
        Developmental Research for New Australian Health Warnings on Tobacco Products. Population Health Division, Department of Health and Ageing, 2003 (Available at:
        • Willemsen M.C.
        • Simons C.
        • Zeeman G.
        Impact of the new EU health warnings on the Dutch quit line.
        Tob Control. 2002; 11: 382
        • Department of Health (UK)
        Consultation on the introduction of picture warnings on tobacco packs. 2006 (May. Available at:

      Linked Article

      • Erratum
        American Journal of Preventive MedicineVol. 32Issue 5
        • Preview
          Erratum to the article by Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: Findings from the International Tobacco Control Four Country Study. Am J Prev Med 2007;32:202–9.
        • Full-Text
        • PDF