Perceived effectiveness of pictorial health warnings among Mexican youth and adults: a population-level intervention with potential to reduce tobacco-related inequities

Abstract

Purpose Pictorial health warnings on cigarette packages are a prominent and effective means of communicating the risks of smoking; however, there is little research on effective types of message content and socio-demographic effects. This study tested message themes and content of pictorial warnings in Mexico. Methods Face-to-face surveys were conducted with 544 adult smokers and 528 youth in Mexico City. Participants were randomized to view 5–7 warnings for two of 15 different health effects. Warnings for each health effect included a text-only warning and pictorial warnings with various themes: “graphic” health effects, “lived experience”, symbolic images, and testimonials. Results Pictorial health warnings were rated as more effective than text-only warnings. Pictorial warnings featuring “graphic” depictions of disease were significantly more effective than symbolic images or experiences of human suffering. Adding testimonial information to warnings increased perceived effectiveness. Adults who were female, older, had lower education, and intended to quit smoking rated warnings as more effective, although the magnitude of these differences was modest. Few interactions were observed between socio-demographics and message theme. Conclusions Graphic depictions of disease were perceived by youth and adults as the most effective warning theme. Perceptions of warnings were generally similar across socio-demographic groups.

Predictive and External Validity of a Pre-Market Study to Determine the Most Effective Pictorial Health Warning Label Content for Cigarette Packages

“…8 A 20-minute computer assisted, interviewer-administered faceto-face survey was conducted using laptop computers. Recruitment sites included two large public parks, a bus terminal, and outside five Walmart stores in Mexico City.…”

“…8 Each set of HWLs that addressed the same health effect included 5 to 7 warnings, with various themes. Images were drawn by authors from actual HWL implemented in several countries and adapted where necessary.…”

“…The themes were defined as follows: (1) Graphic health effects: vivid depiction of physical effects; (2) Lived experience: depiction of personal experience, including social and emotional impact, or implications for quality of life; (3) Symbolic images: representation of message using abstract imagery or symbol; and (4) Testimonial: warnings with a brief narrative describing a personal consequence of smoking, written as a quote from a person in the image, accompanied by their name and age. 8 …”

“…[4][5][6][7][8][9] For example, pre-market experimental studies in Mexico and the United States found that HWLs with graphic imagery that shows gruesome diseased body parts were rated as more effective than both lived experience depicting the social and emotional impact of human suffering from smokingrelated disease, and symbolic images using abstract representation of the health effects. [8][9][10] Experiments in Mexico and the United States also indicate that pictorial HWLs with testimonial content focusing on a real personal story work better than HWLs with didactic content, 10,11 although this is not always the case, especially among people with higher education. 11 While most studies on pictorial HWL content have primarily used experimental, forced-exposure designs with convenience samples, there is limited research on how results from these studies may predict general population responses under conditions of repeated, naturalistic exposure.…”

Global tobacco inequalities: a new frontier

“…Thus, in an era of mobile devices in all parts of the world, radio remains influential. The two related studies from Mexico found that graphic pictorial health warnings that included diseased organs or tobacco victims had a greater impact on participants than symbolic representations or testimonials [19,20]. Furthermore, these effects may be magnified among persons from less advantaged SEP.…”