Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Hammond
David
D
Department of Health Studies & Gerontology, University of Waterloo, Waterloo, Ontario, Canada. dhammond@uwaterloo.ca
Fong
Geoffrey T
GT
Borland
Ron
R
Cummings
K Michael
KM
McNeill
Ann
A
Driezen
Pete
P
D000328:Adult; D001315:Australia; D002170:Canada; D003257:Consumer Product Safety / Q000592:standards*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007391:International Cooperation; D008297:Male; D008875:Middle Aged; D011356:Product Labeling / Q000592:standards*; D012907:Smoking / Q000009:adverse effects*; D000074606:Smoking Prevention; D006113:United Kingdom; D014481:United States