How graphic photos on cigarette packs help smokers consider quitting

Researchers found that smokers who saw graphic warning labels on every pack of cigarettes they smoked for four weeks had more negative feelings about smoking compared to those who saw just text warnings, which led them to look more closely at the warnings and put more credence into them. This was associated with them thinking their habit was more dangerous and being more likely to consider quitting.

They also remembered more of the health risks of their habit.

"The graphic images motivated smokers to think more deeply about their habit and the risks associated with smoking," said Ellen Peters, co-author of the study and professor of psychology at The Ohio State University.

The study appears in the journal PLOS ONE.

The research is the first to look at the impact of graphic warning labels on smokers outside of a laboratory and over a relatively long period of time.

"Our study provides real-world evidence of how viewing these graphic images over time has an impact on smokers beyond what occurs with simple text warnings," said Abigail Evans, lead author of the study and a postdoctoral researcher in psychology at Ohio State.

For the study, the researchers used graphic warning labels created by the U.S. Food and Drug Administration. One of the labels included an image of a man smoking through a hole in his throat, called a tracheostomy. A tracheostomy may be necessary as a result of some smoking-related cancers.

The use of graphic warning labels was mandated by law to appear on cigarette packs in the United States in 2009. The warnings proposed by FDA were later invalidated by a federal appeals court. The court concluded the labels were unconstitutional in part because the images were "unabashed attempts to evoke emotion ... and browbeat consumers into quitting."

This study suggests that the court was not correct in its assessment of how these images work to discourage smoking, Peters said.

"Smokers weren't browbeaten by the images. The images definitely did stir their emotions, but those emotions led them to think more carefully about the risks of smoking and how those risks affected them," Peters said.

"What the court is missing is that without emotions, we can't make decisions. We require having feelings about information we collect in order to feel motivated to act. These graphic warnings helped people to think more carefully about the risks and to consider them more."

The study involved 244 adults who smoked between 5 and 40 cigarettes each day.

Participants were provided with their preferred brand of cigarettes for four weeks, in modified packages. All packages had the same text messages, such as "Cigarettes cause fatal lung disease." Some participants received packs with only these messages. Some received packs with the text warnings plus one of nine graphic, somewhat disturbing images showing the dangers of smoking. A third group received the simple text and the image, plus additional text detailing how every cigarette entails risk.

Participants returned to the lab each week to receive additional cigarettes and respond to surveys about their experiences with the new packaging.

Results showed that smokers who had the warning labels with the graphic labels were more likely than those who received only text warnings to report that the packaging made them feel worse about smoking. They were also more likely to read or look closely at the information on the warning labels and they better remembered what was on the labels.

Smokers who had the graphic labels also saw the warnings as more credible.

"The feelings produced by the graphic images acted as a spotlight. Smokers looked more carefully at the packages and, as a result, the health risks fell into the spotlight and led to more consideration of those risks," Peters said.

Smokers who viewed the graphic labels were also slightly more likely to say they intended to quit smoking.

"For a health issue like smoking, which causes about a half-million deaths a year in the United States, even small effects can have a large impact in the population," Peters said.

"The effect was small, but it was not unimportant."

The results show warning labels with graphic images really do work, Evans said.

"Policies requiring such labels have the potential to reduce the number of Americans who smoke," she said.