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Pictorial Cigarette Pack Warnings: a Meta-Analysis of Experimental Studies

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Review Tob Control: first published as 10.1136/tobaccocontrol-2014-051978 on 6 May 2015. Downloaded from Pictorial cigarette pack warnings: a meta-analysis of experimental studies Seth M Noar,1,2 Marissa G Hall,3 Diane B Francis,1 Kurt M Ribisl,2,3 Jessica K Pepper,2,3 Noel T Brewer2,3 ▸ Additional material is ABSTRACT the implementation of large warnings on tobacco published online only. To view Objective To inform international research and policy, products.6 The treaty’s Article 11 specifies that please visit the journal online (http://dx.doi.org/10.1136/ we conducted a meta-analysis of the experimental health warnings may include pictures, and subse- tobaccocontrol-2014-051978). literature on pictorial cigarette pack warnings. quent guidelines for implementation state that pic- 1 Data sources We systematically searched 7 torial warnings are ‘far more effective’ than School of Journalism and 6 Mass Communication, computerised databases in April 2013 using several search text-only messages. By 2015, implementation of University of North Carolina at terms. We also searched reference lists of relevant articles. pictorial warning policies had occurred in 77 coun- Chapel Hill, Chapel Hill, North Study selection We included studies that used an tries and jurisdictions that are home to nearly 50% Carolina, USA experimental protocol to test cigarette pack warnings and of the world’s population.7 2Lineberger Comprehensive reported data on both pictorial and text-only conditions. As pictorial cigarette pack warnings have prolif- Cancer Center, University of 89 North Carolina at Chapel Hill, 37 studies with data on 48 independent samples erated globally, so has research on their impact. Chapel Hill, North Carolina, (N=33 613) met criteria. Observational studies suggest increased cessation USA 3 Data extraction and synthesis Two independent behaviour after the introduction of pictorial warn- Department of Health coders coded all study characteristics. Effect sizes were ings,10 11 and such studies typically have high exter- Behavior, Gillings School of Global Public Health, University computed from data extracted from study reports and nal validity. However, isolating the effects of of North Carolina at Chapel were combined using random effects meta-analytic pictorial warnings on smoking behaviour in such Hill, Chapel Hill, North procedures. studies has proven difficult because governments Carolina, USA Results Pictorial warnings were more effective than often introduce the warnings alongside other 812 Correspondence to text-only warnings for 12 of 17 effectiveness outcomes tobacco control policies. By contrast, experi- Dr Seth M Noar, School of (all p<0.05). Relative to text-only warnings, pictorial ments can offer strong evidence of the causal Journalism and Mass warnings (1) attracted and held attention better; impact of pictorial warnings, isolating the effects of copyright. Communication, 382 Carroll (2) garnered stronger cognitive and emotional reactions; warnings on key outcomes. For this reason, experi- Hall (CB 3365), University of (3) elicited more negative pack attitudes and negative ments are an important tool for studying the North Carolina at Chapel Hill, Chapel Hill, NC 27599-3365, smoking attitudes and (4) more effectively increased effects of pictorial warnings. USA; [email protected] intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being Previous research on pictorial cigarette pack Received 19 August 2014 more effective than text-only warnings across all 8 warnings Accepted 31 March 2015 Published Online First perceived effectiveness outcomes. A large and growing empirical literature has docu- http://tobaccocontrol.bmj.com/ 6 May 2015 Conclusions The evidence from this international body mented the effects of pictorial cigarette pack warn- of literature supports pictorial cigarette pack warnings as ings. Some evidence suggests that pictures and more effective than text-only warnings. Gaps in the imagery may be more effective than text-only mes- literature include a lack of assessment of smoking sages at communicating health risks.13 14 Compared behaviour and a dearth of theory-based research on how with text-only warnings, pictorial warnings have warnings exert their effects. been associated with stronger beliefs about the harms of smoking and higher motivation to quit – smoking.10 15 21 However, while some studies find that smokers and non-smokers rate pictorial warn- – INTRODUCTION ings as more effective than text-only warnings,22 26 – Tobacco use is the leading cause of preventable other studies have reported conflicting findings.27 29 on September 24, 2021 by guest. Protected death and disease in the world, causing nearly six For instance, studies have found that graphic, pictor- million deaths each year.1 While tobacco product ial warnings result in poorer recall than less graphic packaging is a key part of marketing efforts to make or non-graphic warnings,28 do not increase youth’s 23 29 Open Access tobacco use appealing, regulators can use that expectations to be non-smokers a year later, have Scan to access more free content same packaging to communicate the health risks of no effect on beliefs about cancer or addiction tobacco products to consumers.4 A pack-a-day among non-smoking adolescent boys,26 and are smoker potentially sees a cigarette pack an estimated effective in lowering smoking intentions for 7300 times per year (20 views/day×365 days/year). Canadians but not for Americans.27 Messages on these packs would generate exposure Reviews of the literature on pictorial cigarette far outweighing exposure from other antitobacco pack warnings have taken a variety of approaches. communications, such as mass media campaigns.5 A narrative review by Hammond8 suggested that The combination of high exposure, nearly uni- cigarette pack warnings can be effective in promot- versal reach, and very low cost has made pictorial ing smoking cessation, especially when warnings To cite: Noar SM, Hall MG, warnings on cigarette packs a core tobacco control are large, full-colour, and use graphic images. Francis DB, et al. Tob strategy globally. The WHO Framework While useful and an important contribution for – Control 2016;25:341 354. Convention on Tobacco Control (FCTC) calls for understanding pictorial warnings, this review did Noar SM, et al. Tob Control 2016;25:341–354. doi:10.1136/tobaccocontrol-2014-051978 341 Review Tob Control: first published as 10.1136/tobaccocontrol-2014-051978 on 6 May 2015. Downloaded from not provide a systematic, quantitative synthesis of pictorial METHOD warning effects. A systematic review by Monarrez-Espino et al30 Search strategy examined 21 mostly observational studies of the impact of pic- We used a comprehensive search strategy to locate studies rele- torial warnings on reduced smoking, quit attempts and smoking vant to this meta-analysis. The search strategy involved three cessation. Monarrez-Espino et al found that most of these steps. First, we searched PsycINFO, PubMed, EMBASE, Web of studies were of poor methodological quality; for this reason, Science, Communication & Mass Media Complete, Business their findings on the impact of pictorial warnings on smoking Source Complete, and CINAHL computerised databases in behaviour were inconclusive. Importantly, this review did not April 2013. We used the following Boolean terms: (cigarette* examine many factors that are likely pre-requisites to changes in OR tobacco) AND (warning* OR label* OR pictorial OR behaviour, such as attention to warnings, cognitive and emo- graphic OR messag* OR text*). Second, we examined the refer- tional reactions to warnings, and changes in beliefs about ence sections of five narrative reviews of cigarette pack warn- – smoking. ings.893133 Third, we examined the reference lists of the final While these recent reviews have summarised portions of the set of articles included in our review. We included all reports cigarette pack warnings literature,8930no meta-analysis has that came up in our searches—peer-reviewed journal articles, synthesised the experimental literature on pictorial cigarette book chapters, and grey literature (eg, dissertations, publicly pack warnings. To inform international research and public available reports)—as long as the full text was available. policy, we conducted a meta-analysis of experiments examining To be included, a study had to use an experimental protocol the impact of pictorial cigarette pack warnings. Our research that tested warnings intended for cigarette packs. Studies had to question was: across the body of experimental studies, what are report data on both a pictorial warning condition and a the effects of pictorial cigarette pack warnings compared with text-only condition. The experimental design could be between text warnings? subjects (individuals were randomised to different warning label copyright. http://tobaccocontrol.bmj.com/ on September 24, 2021 by guest. Protected Figure 1 PRISMA flow diagram showing the study screening process. 342 Noar SM, et al. Tob Control 2016;25:341–354. doi:10.1136/tobaccocontrol-2014-051978 Review Tob Control: first published as 10.1136/tobaccocontrol-2014-051978 on 6 May 2015. Downloaded from Table 1 Outcomes assessed in experimental pictorial warning studies Construct Definition Example item Examples of authors’ terminology Attention and recall Attention attracting The extent to which the warning The pack grabbed my attention29 Attract attention, salience attracted or grabbed the
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