Pictorial Cigarette Pack Warnings and Smoking Behavior

Study Questions:

Do pictorial warnings on the front and back of cigarette packs affect smoking behaviors?


This was a 4-week randomized clinical trial, which enrolled adult cigarettes smokers residing in California and North Carolina. Participants were randomized to receive text-only warnings, which are currently in use, on the cigarette packs or pictorial, which show harm related to smoking. The primary outcome was attempting to quit smoking during the 4-week study.


A total 2,149 smokers were enrolled in the trial, of which 88% (n = 1,901) completed the trial. Mean age of the cohort was 39.7 years for the text-only warning group and 39.8 years for the pictorial warnings. For intent-to-treat analyses, participants randomized to the pictorial warnings were more likely to attempt to quit smoking compared to the text-only warnings (40% vs. 34%; odds ratio [OR], 1.29; 95% confidence interval [CI], 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs. 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings were associated with an increased likelihood of forgoing a cigarette, intending to quit, negative emotional reactions, thinking about the harms of smoking, and having conversations about quitting smoking.


The investigators concluded that pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks.


This study suggests that use of pictures to demonstrate the harms of smoking would be helpful to improve smoking quit rates. Consideration of pictures on cigarette packs may have important public health implications.

Clinical Topics: Prevention, Smoking

Keywords: Primary Prevention, Public Health, Smoking, Smoking Cessation, Text Messaging, Tobacco Products, Tobacco Use Disorder, Outcome Assessment (Health Care)

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