Systematic review of eye-tracking experiments evaluating tobacco health warning labels

This systematic review examines eye-tracking experiments evaluating the effects of tobacco health warning labels (HWLs) on visual attention. We focus on eye-tracking metrics (dwell time, fixation counts and time to first fixation) to inform tobacco control strategies.

Controlled keyword searches were conducted in APA PsycINFO, ASSIA, CMMC, CINAHL, Embase, Psychology & Behavioral Sciences Collection, PubMed and Web of Science from January 2018 to December 2023.

Eligible articles (n=25) were peer-reviewed, written in English, involved human participants and included eye-tracking technology to assess attention to HWLs.

Extracted data included article information, HWL characteristics (product type, context, format, source), study design, sample demographics and eye-tracking outcomes. Two trained reviewers collaboratively screened and extracted data following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Across 31 experiments, dwell time was consistently longer for pictorial than textual HWLs, fixation counts increased when packs contained fewer visual distractions, and time to first fixation was shorter for more visually salient HWLs. Greater visual attention was also associated with lower liking of tobacco products and stronger negative emotional responses. Independent t-tests on summary data showed that participants (mostly adult males) spent more time viewing and less time locating pictorial HWLs than text-only HWLs, while fixation counts did not differ significantly.

This review provides eye-tracking evidence aligned with WHO recommendations for pictorial HWLs and highlights key research gaps that future studies should address to strengthen global tobacco control efforts.