title: Educational differences in the impact of pictorial cigarette warning labels on smokers: findings from the International Tobacco Control (ITC) Europe surveys.
abstract: OBJECTIVE
  To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers' educational level.
  
  
  METHODS
  Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.
  
  
  RESULTS
  Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).
  
  
  CONCLUSIONS
  The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.
authors: Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands Dutch Alliance for a Smokefree Society, The Hague, The Netherlands.
authors: Gera E
authors: GE
authors: Nagelhout
authors: Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands Dutch Alliance for a Smokefree Society, The Hague, The Netherlands.
authors: Marc C
authors: MC
authors: Willemsen
authors: Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands.
authors: Hein
authors: H
authors: de Vries
authors: Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany Unit Cancer Prevention, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors: Ute
authors: U
authors: Mons
authors: UK Centre for Tobacco and Alcohol Studies (UKCTAS), London, UK Department of Addictions, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.
authors: Sara C
authors: SC
authors: Hitchman
authors: Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors: Anton E
authors: AE
authors: Kunst
authors: French Institute for Health Promotion and Health Education (INPES), Saint-Denis, France.
authors: Romain
authors: R
authors: Guignard
authors: Department of Health Promotion, Social and Behavioral Health, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA.
authors: Mohammad
authors: M
authors: Siahpush
authors: VicHealth Centre for Tobacco Control, The Cancer Council Victoria, Carlton, Victoria, Australia.
authors: Hua-Hie
authors: HH
authors: Yong
authors: Department of Communication, University of Amsterdam (ASCoR), Amsterdam, The Netherlands Trimbos Institute, Netherlands Institute for Mental Health and Addiction, Utrecht, The Netherlands.
authors: Bas
authors: B
authors: van den Putte
authors: Department of Psychology, School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
authors: Geoffrey T
authors: GT
authors: Fong
authors: Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, South Carolina, USA Department of Tobacco Research, Mexican National Institute of Public Health, Cuernavaca, Mexico.
authors: James F
authors: JF
authors: Thrasher
mesh_terms: D000293:Adolescent; D000328:Adult; D003071:Cognition; D004522:Educational Status; D005060:Europe; D005260:Female; D015438:Health Behavior; D006266:Health Education / Q000379:methods*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010781:Photography; D011356:Product Labeling; D018570:Risk Assessment; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects* / Q000523:psychology; D016540:Smoking Cessation / Q000523:psychology*; D000074606:Smoking Prevention; D011795:Surveys and Questionnaires; D062789:Tobacco Products / Q000009:adverse effects*; D014796:Visual Perception; D055815:Young Adult
keywords: Packaging and Labelling; Public policy; Socioeconomic status