title: Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content.
abstract: OBJECTIVE
  The objective of this study was to determine the most effective content of pictorial health warning labels (HWLs) and whether educational attainment moderates these effects.
  
  
  METHODS
  Field experiments were conducted with 529 adult smokers and 530 young adults (258 nonsmokers; 271 smokers). Participants reported responses to different pictorial HWLs printed on cigarette packages. One experiment involved manipulating textual form (testimonial narrative vs. didactic) and the other involved manipulating image type (diseased organs vs. human suffering).
  
  
  RESULTS
  Tests of mean ratings and rankings indicated that pictorial HWLs with didactic textual forms had equivalent or significantly higher credibility, relevance, and impact than pictorial HWLs with testimonial forms. Results from mixed-effects models confirmed these results. However, responses differed by participant educational attainment: didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In the second experiment, with textual content held constant, greater credibility, relevance, and impact was found for graphic imagery of diseased organs than imagery of human suffering.
  
  
  CONCLUSIONS
  Pictorial HWLs with didactic textual forms seem to work better than those with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.
authors.affiliation: Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter Street, Columbia, SC 29208, USA. thrasher@mailbox.sc.edu
authors.forename: James F
authors.initials: JF
authors.lastname: Thrasher
authors.forename: Edna
authors.initials: E
authors.lastname: Arillo-Santillán
authors.forename: Victor
authors.initials: V
authors.lastname: Villalobos
authors.forename: Rosaura
authors.initials: R
authors.lastname: Pérez-Hernández
authors.forename: David
authors.initials: D
authors.lastname: Hammond
authors.forename: Jarvis
authors.initials: J
authors.lastname: Carter
authors.forename: Ernesto
authors.initials: E
authors.lastname: Sebrié
authors.forename: Raul
authors.initials: R
authors.lastname: Sansores
authors.forename: Justino
authors.initials: J
authors.lastname: Regalado-Piñeda
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004522:Educational Status; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008800:Mexico; D008875:Middle Aged; D011356:Product Labeling / Q000379:methods*; D012907:Smoking / Q000009:adverse effects* / Q000523:psychology; D000074606:Smoking Prevention; D055815:Young Adult