Do Graphic Anti-Tobacco Warnings Work?

As background information, in 2009, the Family Smoking Prevention and Tobacco Control Act required graphic warnings on cigarette packs and in at least 20% of cigarette advertising, but the tobacco industry quickly sued the FDA to keep the images off their products and in 2011, a federal judge sided with Big Tobacco, based on their First Amendment free speech rights. The FDA has yet to issue a new rule requiring graphic warning despite a lawsuit by a number of public health groups.

There are published data supporting the proposition that graphic images depicting the harms of smoking are effective. In a study from 2016, published in JAMA Internal Medicine, researchers found that graphic pictorial warnings (eg. rotting teeth, badly diseased lung, tracheostomy hole) effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking. In a study from Georgetown University Medical Center, young adult participants (ages 18-30) who viewed graphic warning labels were more motivated to quit smoking than were those who did not see graphic images.

A novel research study┬ájust published, researchers constructed a mock 1,500 square foot fully-equipped convenience store (including tobacco wall behind the checkout counter) to test the efficacy of a graphic pictorial warning at a point-of-sale location (which is ground-zero for Big Tobacco advertising). The study involved 441 adolescents (11-17 years old), who were surveyed about their attitudes towards cigarettes and on a number of different shopping interests both before and after visiting the mock store. About 5% reported a prior history of smoking and about 20% were considered “high risk” for future cigarette use. A poster with graphic image (a close-up of a smoker’s mouth with cancerous lesions and discolored teeth caused by smoking and warning that cigarettes cause cancer) was placed either near the tobacco wall, near the cash register, both locations, or not at all.

What did they find?

The graphic image had no impact on committed never smokers, no matter the location. However, in a counterintuitive response, those adolescents at high risk for future use actually revealed a statistically significant (p<0.045) heightened smoking susceptibility after viewing the graphic image. Why this occurred is not known, but might be explained by a defensive reaction, causing the adolescent to discount or downplay the health risks portrayed by the poster.

This study may have important implications for tobacco control policy makers. For high-risk adolescents, graphic images may actually do the opposite of their intended result.