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      Pictorial cigarette pack warnings: a meta-analysis of experimental studies

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          Abstract

          Objective

          To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings.

          Data sources

          We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles.

          Study selection

          We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria.

          Data extraction and synthesis

          Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures.

          Results

          Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes.

          Conclusions

          The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

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          Most cited references81

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          Evaluative conditioning in humans: a meta-analysis.

          This article presents a meta-analysis of research on evaluative conditioning (EC), defined as a change in the liking of a stimulus (conditioned stimulus; CS) that results from pairing that stimulus with other positive or negative stimuli (unconditioned stimulus; US). Across a total of 214 studies included in the main sample, the mean EC effect was d = .52, with a 95% confidence interval of .466-.582. As estimated from a random-effects model, about 70% of the variance in effect sizes were attributable to true systematic variation rather than sampling error. Moderator analyses were conducted to partially explain this variation, both as a function of concrete aspects of the procedural implementation and as a function of the abstract aspects of the relation between CS and US. Among a range of other findings, EC effects were stronger for high than for low contingency awareness, for supraliminal than for subliminal US presentation, for postacquisition than for postextinction effects, and for self-report than for implicit measures. These findings are discussed with regard to the procedural boundary conditions of EC and theoretical accounts about the mental processes underlying EC. (c) 2010 APA, all rights reserved.
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            Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey.

            D. Hammond (2006)
            Health warnings on cigarette packages are among the most common means of communicating the health risks of smoking. However, few studies have evaluated the impact of package warnings on consumer knowledge about tobacco risks. The aim of the current study was to use nationally representative samples of adult smokers from the United States (USA), the United Kingdom (UK), Canada (CAN), and Australia (AUS) from the International Tobacco Control Four Country Survey (ITC-4) to examine variations in smokers' knowledge about tobacco risks and the impact of package warnings. A telephone survey was conducted with 9058 adult smokers from the following countries: USA (n = 2138), UK (n = 2401), CAN (n = 2214) and AUS (n = 2305). Respondents were asked to state whether they believed smoking caused heart disease, stroke, impotence, lung cancer in smokers, and lung cancer in non-smokers. Respondents were also asked whether the following chemicals are found in cigarette smoke: cyanide, arsenic and carbon monoxide. Smokers in the four countries exhibited significant gaps in their knowledge of the risks of smoking. Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease. In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge. For example, in Canada, where package warnings include information about the risks of impotence, smokers were 2.68 (2.41-2.97) times more likely to agree that smoking causes impotence compared to smokers from the other three countries. Smokers are not fully informed about the risks of smoking. Warnings that are graphic, larger, and more comprehensive in content are more effective in communicating the health risks of smoking.
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              Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study.

              Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the United States. The current study examined the effectiveness of health warnings on cigarette packages in four countries. Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (n=14,975): Canada (n=3687), United States (n=4273), UK (n=3634), and Australia (n=3381). Surveys were conducted between 2002 and 2005, before and at three time points following implementation of new package warnings in the UK. At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave. Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.
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                Author and article information

                Journal
                9209612
                20367
                Tob Control
                Tob Control
                Tobacco control
                0964-4563
                1468-3318
                5 June 2015
                06 May 2015
                May 2016
                01 May 2016
                : 25
                : 3
                : 341-354
                Affiliations
                [1 ]School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
                [2 ]Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
                [3 ]Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
                Author notes
                Correspondence to Dr Seth M Noar, School of Journalism and Mass Communication, 382 Carroll Hall (CB 3365), University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3365, USA; noar@ 123456email.unc.edu
                Article
                NIHMS696401
                10.1136/tobaccocontrol-2014-051978
                4636492
                25948713
                2cd23c79-e1b3-4f57-9bf6-9c55890d4ed8

                This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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                Public health
                Public health

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