Background Pictorial health warnings are more effective than text warnings in enhancing motivation to quit and not to start smoking among youth. In Lebanon, packs still have only a very small text warning. The aim of this study was to evaluate the perceived effectiveness of pictorial health warnings on cigarette packs among Lebanese youth.

Methods This was a cross-sectional study including school students (n=1412) aged 13–18 years recruited from 28 schools and university students (n=1217) aged 18–25 years recruited from 7 universities. A variety of warnings were adapted from other countries. In all, 4 warnings were tested among school students and 18 among university students.

Results All pictorial warnings were considered more effective than the current text warning on message-related and impact-related variables, including intentions to quit or not to start smoking among school and university students. Selected examples related to the top-ranked pictorial warnings are: among male non-smoking school students, 81% agreed that the ‘lung’ warning had more impact on their intentions not to start smoking as compared to 57% for the current text warning (p<0.001) with a significant difference compared to the current text warning; among female non-smoking university students, 75% agreed that the ‘economic impact’ pictorial had more impact on their intentions not to start smoking with significant difference as compared to 43% for the current text warning (p value=0.001); finally, the ‘heart attack’ pictorial resulted in 52% of male university students smokers stating they intended to quit as opposed to 20% for the current text warning (p value=0.019).

Conclusions The results of the present study add to the general international literature on the impact of pictorial warnings on youth and young adults. This study is also the first to test a non-health pictorial warning about the negative economic consequences of smoking, and to find that such a warning was effective among specific sociodemographic groups.