Background and Aims Graphic warning labels (GWLs) on cigarette packs have been adopted by many jurisdictions world‐wide. In the United States, the introduction of GWLs has been delayed by claims that their high level of negative emotional arousal unnecessarily infringed upon the tobacco manufacturers’ free speech. This study aimed to provide experimental data on the contribution of emotional arousal to GWL efficacy. Design Observational study using long‐term naturalistic exposure and functional magnetic resonance imaging. Setting Research university in Philadelphia, PA, USA. Participants A total of 168 adult smokers. Measurements For 4 weeks, participants received cigarettes in packs that carried either high‐arousal or low‐arousal GWLs (n = 84 versus 84). Smoking behavior, quitting‐related cognitions and GWL‐induced brain response were measured before and after the 4‐week exposure. The amygdala and medial prefrontal cortex served as regions of interest. Findings Compared with the high‐arousal group, the low‐arousal group smoked fewer cigarettes [log10‐transformed, 1.076 versus 1.019; difference = 0.056, 95% confidence interval (CI) = 0.027, 0.085, χ2(1) = 14.21, P < 0.001] and showed stronger intention to quit (2.527 versus 2.810; difference = −0.283, 95% CI = −0.468, –0.098, χ2(1) = 8.921, P = 0.007) and endorsement of the GWLs’ textual component (4.805 versus 5.503; difference = −0.698, 95% CI = −1.016, −0.380, χ2(1) = 18.47, P < 0.001). High‐arousal GWLs induced greater amygdala response than low‐arousal GWLs (0.157 versus 0.052; difference = 0.105, 95% CI = 0.049, 0.161, χ2(1) = 23.52, P < 0.001), although the response to high‐arousal GWLs declined over time (slope = −0.087 versus 0.016; difference = −0.103, 95% CI = −0.198, –0.009, χ2(1) = 6.370, P = 0.046). Greater baseline amygdala response was associated with more smoking at 4 weeks in the high‐arousal group, but less smoking in the low‐arousal group (slope = 0.179 versus −0.122; difference = 0.287, 95% CI = 0.076, 0.498, χ2(1) = 7.086, P = 0.008). Medial prefrontal response did not differ significantly between groups. Conclusions High‐arousal cigarette graphic warning labels (GWLs) appear to be less efficacious than low‐arousal GWLs. The high emotional reaction that high‐arousal GWLs elicit wanes over time. Baseline amygdala response negatively predicts efficacy of high‐arousal GWLs and positively predicts efficacy of low‐arousal GWLs. High emotional arousal may not be required for sustained GWL efficacy.

The results suggest that emotional salience of GWLs facilitates cognitive processing of the textual warnings, resulting in better remembering of the information about the health hazards of smoking. Thus, high emotional salience of the pictorial component of GWLs is essential for their overall effectiveness.

IntroductionMentholated tobacco cigarettes are believed to be more addictive than non-menthol ones. Packaging of most menthol cigarette brands includes distinctive green hues, which may act as conditioned stimuli (ie, cues) and promote menthol smoking. To examine the cue properties of menthol cigarette packaging, we used a priming paradigm to assess the effect of packaging on the neural substrates of smoking cue reactivity. We hypothesised that menthol packaging will exert a specific priming effect potentiating smoking cue reactivity in menthol compared with non-menthol smokers.MethodsForty-two menthol and 33 non-menthol smokers underwent functional MRI while viewing smoking and neutral cues. The cues were preceded (ie, primed) by briefly presented images of menthol or non-menthol cigarette packages. Participants reported craving for cigarettes in response to each cue.ResultsMenthol packaging induced greater frontostriatal and occipital smoking cue reactivity in menthol smokers than in non-menthol smokers. Menthol packaging also enhanced the mediation by neural activity of the relationship between cue exposure and cigarette craving in menthol but not non-menthol smokers. Dynamic causal modelling showed stronger frontostriatal-occipital connectivity in response to menthol packaging in menthol compared with non-menthol smokers. The effects of non-menthol packaging did not differ between categories of smokers.ConclusionsOur findings demonstrate heightened motivational and perceptual salience of the green-hued menthol cigarette packaging that may exacerbate menthol smokers’ susceptibility to smoking cues. These effects could contribute to the greater addiction severity among menthol smokers and could be considered in the development of science-based regulation and legal review of tobacco product marketing practices.

Studies testing the benefits of enriching smoking-cessation video ads with attention-grabbing sensory features have yielded variable results. Dopamine transporter gene (DAT1) has been implicated in attention deficits. We hypothesized that DAT1 polymorphism is partially responsible for this variability. Using functional magnetic resonance imaging, we examined brain responses to videos high or low in attention-grabbing features, indexed by “message sensation value” (MSV), in 53 smokers genotyped for DAT1. Compared to other smokers, 10/10 homozygotes showed greater neural response to High- vs. Low-MSV smoking-cessation videos in two a priori regions of interest: the right temporoparietal junction and the right ventrolateral prefrontal cortex. These regions are known to underlie stimulus-driven attentional processing. Exploratory analysis showed that the right temporoparietal response positively predicted follow-up smoking behavior indexed by urine cotinine. Our findings suggest that responses to attention-grabbing features in smoking-cessation messages is affected by the DAT1 genotype.

Purpose Argument strength (AS) is a validated measure of persuasiveness that has been identified as one of the key variables determining the effectiveness of video ads. Smoking-cessation videos with high AS are more effective at reducing smoking behavior than videos with low AS. The neural processes that mediate the effects of AS on subsequent smoking have not been identified. In the present study, we tested whether the efficacy of high-AS smoking-cessation videos is determined by the level of integration of visual and auditory (ie, multisensory) processes. In addition, we tested differences in sensation seeking, which is repeatedly associated with smokers’ sensitivity to cessation interventions. Patients and methods Using functional magnetic resonance imaging (fMRI), we recorded the brain response of 66 smokers randomly assigned to view either 16 high-AS or 16 low-AS smoking-cessation videos. Multisensory processing was assessed by the functional connectivity between brain regions that encoded visual and auditory information in the videos. Smoking behavior was indexed by the urine level of cotinine, a nicotine metabolite, immediately before and approximately 30 days after the fMRI session. Results We found a significant moderated mediation effect, such that the connectivity between visual and auditory cortices mediated the effect of AS on subsequent smoking, but only for smokers lower in sensation seeking. The prediction performance of the model was confirmed by leave-one-out cross-validation. Conclusion Our study suggests that audiovisual integration underlies the greater efficacy of high- vs low-AS smoking-cessation videos for individuals lower in sensation seeking. High-sensation-seeking smokers may be responsive to other characteristics of smoking-cessation videos.