title: "Pictures don't lie, seeing is believing": exploring attitudes to the introduction of pictorial warnings on cigarette packs in Ghana.
abstract: OBJECTIVE
  To compare perceptions of text and pictorial warning labels on cigarette packs among Ghanaian smokers and nonsmokers and to explore their views on the introduction of pictorial warnings in Ghana.
  
  
  METHODS
  Qualitative study involving 12 focus group discussions with 50 smokers and 35 nonsmokers aged 15 years and older in Kumasi, Ghana. Semistructured discussion guides along with visual discussant aids were used to explore the perception, acceptance, and potential use of pictorial warning labels in Ghana.
  
  
  RESULTS
  Health warnings combining text and a picture were perceived by both smokers and nonsmokers to communicate health messages more effectively than text-only or picture-only warnings. The effect of text-only warnings was considered limited by low levels of literacy and by the common practice of single stick sales rather than sales of packs. Of the 6 health warnings tested, lung cancer, blindness, stroke, and throat/mouth cancer messages were perceived to have the most impact on smoking behavior, including uptake and quit attempts.
  
  
  CONCLUSIONS
  Warning labels combining pictures and text have the potential to reduce smoking uptake, increase quit attempts, and reduce smoking appeal among smokers and nonsmokers in Ghana. Measures to prevent single stick sales, or to promote health messages to purchasers of single sticks, are required.
authors.affiliation: Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; artisingh_uk@yahoo.com.
authors.forename: Arti
authors.initials: A
authors.lastname: Singh
authors.affiliation: Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana;
authors.forename: Ellis
authors.initials: E
authors.lastname: Owusu-Dabo
authors.affiliation: UK Centre for Tobacco and Alcohol Studies, Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK;
authors.forename: John
authors.initials: J
authors.lastname: Britton
authors.affiliation: UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, UK; MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK;
authors.forename: Marcus R
authors.initials: MR
authors.lastname: Munafò
authors.affiliation: UK Centre for Tobacco and Alcohol Studies, Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK.
authors.forename: Laura L
authors.initials: LL
authors.lastname: Jones
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D003469:Culture; D005260:Female; D017144:Focus Groups / Q000379:methods*; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010775:Photic Stimulation / Q000379:methods; D011356:Product Labeling / Q000379:methods*; D012907:Smoking / Q000453:epidemiology; D016540:Smoking Cessation / Q000379:methods; D000074606:Smoking Prevention; D062789:Tobacco Products / Q000009:adverse effects; D055815:Young Adult