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Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study
  1. Geoffrey T Fong1,2,
  2. David Hammond1,
  3. Yuan Jiang3,
  4. Qiang Li1,3,
  5. Anne C K Quah1,
  6. Pete Driezen1,
  7. Mi Yan1,
  8. for the ITC China Project Team
  1. 1University of Waterloo, Waterloo, Ontario, Canada
  2. 2Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  3. 3National Office of Tobacco Control, China Center for Disease Control and Prevention, Beijing, China
  1. Correspondence to Geoffrey T Fong, Department of Psychology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1; gfong{at}


Objective To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries.

Method 1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking.

Results Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex.

Conclusions (1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China.

  • Health warnings
  • china
  • tobacco control
  • cigarette packaging
  • ITC Project
  • packaging and labelling
  • public policy

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  • Funding This study was supported by a grant from the Bloomberg Initiative to Reduce Tobacco Use, through the Campaign for Tobacco-Free Kids. Additional support was provided by the Propel Centre for Population Health Impact at the University of Waterloo and by the Ontario Institute for Cancer Research.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Institutional Review Board of the China National CDC and by the Human Research Ethics Committee at the University of Waterloo.

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

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