Graphic warnings on cigarette labels caused smokers to hide their packs

Participants were randomized to receive their cigarettes in one of three packaging designs: plain packaging, standard packaging available commercially in the United States, or packaging with a graphic warning label used on cigarette packets. cigarettes in Australia (licensed by the Australian government).

In the United States, smokers who received cigarette packs with graphic warning labels hid their packs 38% more often. However, smokers stopped hiding their cigarettes when they returned to regular packs without the graphic labels, reports a multi-institutional group of public health experts led by the University of California, San Diego.

“In a randomized clinical trial, we demonstrated that smokers in the United States who received cigarettes in packs with graphic warning labels were less likely to display the packs in public. It was hypothesized that this behavior may reduce teens’ perception that smoking is socially acceptable, possibly explaining why mandatory graphic warning label packs are associated with reduced teen smoking,” said first author John P. Pierce, Ph.D., Professor Emeritus at the Hebert Wertheim School of Public Health and Human Longevity Science at the University of California, San Diego.

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John P. Pierce, Ph.D., professor emeritus at the Hebert Wertheim School of Public Health and Human Longevity Science at UC San Diego

In an article published in the June 2, 2022 online issue of JAMA Network Open, Pierce and colleagues at UC San Diego Moores Cancer Center, California State University San Marcos and Public Health Departments of San Diego County have made special cigarette packs incorporating graphic images of a sick foot, newborn baby with a breathing tube or throat cancer on cigarette packs in Australia (under license from the Australian government) .

Study participants included 357 smokers living in San Diego who agreed to purchase their favorite brand of cigarettes from a study website. Participants were randomized to receive their cigarettes in one of three packaging designs: packaging with a graphic warning label, plain packaging, or standard packaging available commercially in the United States. Around 19,000 kits were delivered to participants.

Graphic warning labels are used on cigarette packs in over 120 countries. Although mandated by the US Congress in 2009, the implementation of graphic warning labels has been delayed by legal challenges from the tobacco industry.

“Prior to the study, we found that many smokers in the United States were discreet and said they hid their usual pack in public places. Packages with graphic warning labels had their biggest effect on those who were the least likely to hide their packaging before the study,” said lead author David R. Strong, Ph.D., a professor at the Herbert Wertheim School of Public Health. “We found no evidence that the packs of warning graphics changed smoking behavior over the one-year study.”

The individuals continued to smoke as often as before and after the study.

During the study, participants were asked, via interactive text messaging, if in the previous four hours they had placed their bags where others would not see them. Changes in consumption and smoking status were assessed at the end of the three-month intervention and at the end of the 12-month study.

Participants who received cigarettes in a standard US pack or in a blank pack without marketing did not change their pack concealment behavior. Smokers randomized to the graphic warning label arm reported that they increased package concealment during the first four weeks of the intervention and continued at the new level until the end of intervention. After ceasing to receive packs labeled with graphic warnings, they quickly reverted to base pack hiding levels.

When social reactions were queried at the end of the study, the group with graphic warning label packs reported that observers had aversive reactions to cigarette packs while those in the blank packs group reported that observers had expressed positive interest in the study, the authors said. .

Co-authors include: Sheila Kealey, Eric C. Leas, Matthew D. Stone, Jesica Oratowski, Elizabeth Brighton, all from UC San Diego; Kim Pulvers, CSU San Marcos; and Adriana Villaseñor, San Diego County Public Health Services.

This research was supported, in part, by the National Cancer Institute (RO1 CA190347, RO1 CA234539) and a grant from the Tobacco Related Diseases Research Program (28DT-0005).

Disclosures: No conflicts of interest were reported.

DOI: 10.1001/jamanetworkopen.2022.14242


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