title: Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers' Cigarette Packs.
abstract: BACKGROUND
  Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings.
  
  
  METHODS
  We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week.
  
  
  RESULTS
  Participants reported low avoidance (<34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels.
  
  
  CONCLUSIONS
  U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.
authors.affiliation: Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO; amcqueen@dom.wustl.edu.
authors.forename: Amy
authors.initials: A
authors.lastname: McQueen
authors.affiliation: Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO;
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Kreuter
authors.affiliation: Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO;
authors.forename: Sonia
authors.initials: S
authors.lastname: Boyum
authors.affiliation: Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO;
authors.forename: Vetta S
authors.initials: VS
authors.lastname: Thompson
authors.affiliation: Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO;
authors.forename: Charlene A
authors.initials: CA
authors.lastname: Caburnay
authors.affiliation: Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO;
authors.forename: Erika A
authors.initials: EA
authors.lastname: Waters
authors.affiliation: Department of Communications, University of Utah, Salt Lake City, UT;
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Kaphingst
authors.affiliation: Scottrade, Inc., St. Louis, MO;
authors.forename: Suchitra
authors.initials: S
authors.lastname: Rath
authors.affiliation: Department of Biostatistics, Saint Louis University, College for Public Health and Social Justice, Salus Center, St. Louis, MO.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Fu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011356:Product Labeling / Q000379:methods*; D012907:Smoking / Q000453:epidemiology* / Q000523:psychology*; D016540:Smoking Cessation / Q000379:methods / Q000523:psychology; D000074606:Smoking Prevention; D011795:Surveys and Questionnaires; D062789:Tobacco Products / Q000009:adverse effects*; D014481:United States / Q000453:epidemiology; D014486:United States Food and Drug Administration; D055815:Young Adult