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Impact of graphic and text warnings on cigarette packs: findings from four countries over five years
  1. R Borland1,
  2. N Wilson2,
  3. G T Fong3,4,
  4. D Hammond3,
  5. K M Cummings5,
  6. H-H Yong1,
  7. W Hosking6,
  8. G Hastings7,
  9. J Thrasher8,
  10. A McNeill9
  1. 1
    The Cancer Council Victoria, Melbourne, Australia
  2. 2
    Otago University, Wellington, New Zealand
  3. 3
    University of Waterloo, Waterloo, Canada
  4. 4
    Ontario Institute for Cancer Research, Toronto, Canada
  5. 5
    Roswell Park Cancer Institute, Buffalo, New York, USA
  6. 6
    Victoria University, Melbourne, Australia
  7. 7
    University of Stirling and The Open University, Stirling, UK
  8. 8
    University of South Carolina, USA
  9. 9
    University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Ron Borland, VicHealth Centre for Tobacco Control, The Cancer Council Victoria, 1 Rathdowne Street, Carlton, VIC 3053, Australia; Ron.Borland{at}


Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out.

Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n = 17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings.

Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (text-only) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones.

Conclusions: Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

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  • Funding This research was funded by grants from the National Cancer Institute of the United States (R01 CA 100362), the Roswell Park Transdisciplinary Tobacco Use Research Center (P50 CA111236), Robert Wood Johnson Foundation (045734), Canadian Institutes of Health Research (57897 and 79551), National Health and Medical Research Council of Australia (265903 and 450110), Cancer Research UK (C312/A3726) and Canadian Tobacco Control Research Initiative (014578), with additional support from the Centre for Behavioural Research and Program Evaluation, National Cancer Institute of Canada/Canadian Cancer Society.

  • Competing interests None.

  • Ethics approval The study protocol was approved by the institutional review boards or research ethics boards of the University of Waterloo (Canada), Roswell Park Cancer Institute (United States), University of Strathclyde (UK), University of Stirling (UK), The Open University (UK) and The Cancer Council Victoria (Australia).

  • Provenance and peer review Not commissioned; externally peer reviewed.