title: The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: longitudinal findings from the International Tobacco Control (ITC) Uruguay Survey.
abstract: BACKGROUND
  Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines recommend that health warning labels (HWLs) should occupy at least 50% of the package, but the tobacco industry claims that increasing the size would not lead to further benefits. This article reports the first population study to examine the impact of increasing HWL size above 50%. We tested the hypothesis that the 2009/2010 enhancement of the HWLs in Uruguay would be associated with higher levels of effectiveness.
  
  
  METHODS
  Data were drawn from a cohort of adult smokers (≥18 years) participating in the International Tobacco Control (ITC) Uruguay Survey. The probability sample cohort was representative of adult smokers in five cities. The surveys included key indicators of HWL effectiveness. Data were collected in 2008/09 (prepolicy: wave 2) and 2010/11 (postpolicy: wave 3).
  
  
  RESULTS
  Overall, 1746 smokers participated in the study at wave 2 (n=1379) and wave 3 (n=1411). Following the 2009/2010 HWL changes in Uruguay (from 50% to 80% in size), all indicators of HWL effectiveness increased significantly (noticing HWLs: OR=1.44, p=0.015; reading HWLs: OR=1.42, p=0.002; impact of HWLs on thinking about risks of smoking: OR=1.66, p<0.001; HWLs increasing thinking about quitting: OR=1.76, p<0.001; avoiding looking at the HWLs: OR=2.35, p<0.001; and reports that HWLs stopped smokers from having a cigarette 'many times': OR=3.42, p<0.001).
  
  
  CONCLUSIONS
  The 2009/2010 changes to HWLs in Uruguay, including a substantial increment in size, led to increases of key HWL indicators, thus supporting the conclusion that enhancing HWLs beyond minimum guideline recommendations can lead to even higher levels of effectiveness.
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Shannon
authors.initials: S
authors.lastname: Gravely
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Fong
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Pete
authors.initials: P
authors.lastname: Driezen
authors.affiliation: Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Mary
authors.initials: M
authors.lastname: McNally
authors.affiliation: Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Thrasher
authors.affiliation: Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Thompson
authors.affiliation: Facultad de Ciencias Sociales, Universidad de la República, Montevideo, Uruguay.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Boado
authors.affiliation: Centro de Investigación para la Epidemia del Tabaquismo, Montevideo, Uruguay.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bianco
authors.affiliation: The Cancer Council Victoria, Melbourne, Victoria, Australia.
authors.forename: Ron
authors.initials: R
authors.lastname: Borland
authors.affiliation: School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Hammond
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011356:Product Labeling; D000074606:Smoking Prevention; D013997:Time Factors; D014583:Uruguay; D014026:Nicotiana
keywords: Global health; Harm Reduction; Low/Middle income country; Packaging and Labelling