Pictures warning of smoking dangers on cigarette packs increased quit attempts

Reducing smoking is a top public health priority because it is a leading cause of preventable death. While the 2009 Family Smoking Prevention and Tobacco Control Act requires pictorial warnings, their implementation was stalled by a 2012 lawsuit by the tobacco industry. The U.S. Court of Appeals for the District of Columbia Circuit ruled against nine pictorial warnings proposed by the U.S. Food and Drug Administration, saying the FDA had "not provided a shred of evidence" that the pictorial warnings reduce smoking. Research suggests pictorial warnings may be more effective than text-only warnings, according to the study background.

Noel T. Brewer, Ph.D., of the University of North Carolina, Chapel Hill, and coauthors sought to address gaps in the research with a large randomized clinical trial that examined the effects on smoking behavior by adding pictorial warnings to the fronts and backs of cigarette packs.

The authors used four pictorial warnings that contained text required by the Tobacco Control Act and a picture illustrating the harm of smoking from the FDA's originally proposed set of images. In addition, four text-only warnings contained U.S. Surgeon General warning statements that have been required on the side of cigarette packs since 1985.

The four-week trial included adult smokers in California and North Carolina. Of the 2,149 smokers who were enrolled in the study, 1,901 individuals completed it. Participants were randomly assigned to receive either text-only or pictorial warnings on their cigarette packs for four weeks. Research staff placed the warnings on cigarette packs smokers brought with them when they attended weekly follow-up visits. Surveys were administered at the start of the study and at each visit.

The authors found smokers whose cigarette packs had pictorial warnings were more likely to try to quit during the four week trial, with 40 percent of smokers in the pictorial warning group making a quit attempt compared with 34 percent in the text-only warning group. Also, 5.7 percent of smokers who received pictorial warnings had quit smoking for at least a week by the end of the trial compared with 3.8 percent of smokers who received text-only warnings, according to the results.

The authors note the effects "appear modest, but they could have a substantial benefit across the population of U.S. smokers."

Study limitations include not knowing what effects pictorial warnings may have over a longer period of time and participant self-selection could have resulted in a study population with a greater interest in quitting smoking than the general population.

"Implementation of pictorial cigarette pack warnings in the United States is on hiatus. Our trial findings provide timely and important information as the United Sates and other countries consider requiring pictorial cigarette pack warnings. The World Health Organization Framework Convention on Tobacco Control now recommends pictorial warnings but stops shorts of requiring them. Our trial findings support strengthening the treaty to require pictorial warnings on cigarette packs," the study concludes.