How Do People Who Smoke Respond to Novel Tobacco Pack Warnings? Two Cross-Sectional Studies from Aotearoa New Zealand

On-pack pictorial warning labels (PWLs) typically feature graphic health risks of smoking. We examined whether expanding the themes featured could increase PWLs' potential effectiveness.

We conducted two online studies: an assessment survey (n = 783) and a discrete choice experiment (DCE) (n = 970) to estimate the impact of price, health, family, and addiction warning themes. Assessment survey respondents rated the likely effect on smoking and quitting-related behaviors of 12 warning images. DCE respondents saw eight sets of four PWLs that combined images and headlines and chose those most likely and least likely to encourage them to think about quitting. Both studies used a PWL featuring a cancerous tongue as a control.

The assessment survey found images from the health, family, and price themes elicited similar responses to the control, but in some cases were judged more effective. However, all addiction images were significantly less effective than the control. The DCE sample comprised two distinct segments: one responded significantly more strongly to price and family PWLs, while the other was more responsive to a health PWL than to the control.

PWLs featuring monetary savings, empathetic health messages, and family-oriented benefits can stimulate thoughts of quitting more effectively than a health-oriented PWL designed to arouse fear. Countries introducing or refreshing PWLs should consider more diverse warning themes that provide different motivations to become smoke-free; these are potentially likely to be at least as effective, if not more effective, than graphic health PWLs.

PWLs conveying the financial costs of smoking and communicating empathetic health messages and family-oriented risks may stimulate thoughts of quitting more effectively than a control using a health-oriented PWL designed to arouse fear. Priority groups' differing responses to PWLs support earlier work that recommended complementing health-oriented PWLs with warnings featuring more diverse themes. Countries considering introducing or refreshing tobacco pack warnings should consider developing PWLs that recognize smoking's impact on well-being in its broader sense, given these appear as effective, if not more effective, than PWLs featuring graphic health images.