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Cigarette packet warning labels can prevent relapse: findings from the International Tobacco Control 4-Country policy evaluation cohort study
  1. Timea Reka Partos1,
  2. Ron Borland1,
  3. Hua-H Yong1,
  4. James Thrasher2,
  5. David Hammond3
  1. 1VicHealth Centre for Tobacco Control, The Cancer Council Victoria, Carlton, Victoria, Australia
  2. 2Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
  3. 3Department of Health Studies and Gerontology, University of Waterloo, West Waterloo, Ontario, Canada
  1. Correspondence to Dr Ron Borland, Nigel Gray Distinguished Fellow in Cancer Prevention, VicHealth Centre for Tobacco Control, The Cancer Council Victoria, 100 Drummond St. Carlton, VIC 3053, Australia; ron.borland{at}


Objectives To investigate the links between health warning labels (WLs) on cigarette packets and relapse among recently quit smokers.

Design Prospective longitudinal cohort survey.

Setting Australia, Canada, the UK and the USA.

Participants 1936 recent ex-smokers (44.4% male) from one of the first six waves (2002–2007) of the International Tobacco Control 4-Country policy evaluation survey, who were followed up in the next wave.

Main outcome measures Whether participants had relapsed at follow-up (approximately 1 year later).

Results In multivariate analysis, very frequent noticing of WLs among ex-smokers was associated with greater relapse 1 year later (OR: 1.52, 95% CI 1.11 to 2.09, p<0.01), but this effect disappeared after controlling for urges to smoke and self-efficacy (OR: 1.29, 95% CI 0.92 to 1.80, p=0.135). In contrast, reporting that WLs make staying quit ‘a lot’ more likely (compared with ‘not at all’ likely) was associated with a lower likelihood of relapse 1 year later (OR: 0.65, 95% CI 0.49 to 0.86, p<0.01) and this effect remained robust across all models tested, increasing in some.

Conclusions This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit. Once the authors control for greater exposure to cigarettes, which is understandably predictive of relapse, WL effects are positive. However, it may be that ex-smokers need to actively use the health consequences that WLs highlight to remind them of their reasons for quitting, rather than it being something that happens automatically. Ex-smokers should be encouraged to use pack warnings to counter urges to resume smoking. Novel warnings may be more likely to facilitate this.

  • Cessation
  • packaging and labelling
  • public policy
  • addiction
  • environmental tobacco smoke
  • end game
  • older people and smoking
  • advertising and promotion
  • health communication
  • media campaigns
  • qualitative study
  • public opinion polls
  • smoking topography
  • population health
  • nicotine reduction in cigarettes
  • tobacco products

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  • Funding The ITC Four-Country Survey is supported by multiple grants including R01 CA 100362 and P50 CA111236 (Roswell Park Transdisciplinary Tobacco Use Research Center) and also in part from grant P01 CA138389 (Roswell Park Cancer Institute, Buffalo, New York), all funded by the National Cancer Institute of the United States, Robert Wood Johnson Foundation (045734), Canadian Institutes of Health Research (57897, 79551), National Health and Medical Research Council of Australia (265903, 450110, APP1005922), Cancer Research UK (C312/A3726), Canadian Tobacco Control Research Initiative (014578); Centre for Behavioural Research and Program Evaluation, National Cancer Institute of Canada/Canadian Cancer Society. The funding agencies had no role in the study design; collection, analysis or interpretation of data; writing of the manuscript or the decision to submit the manuscript for publication.

  • Competing interests None.

  • Patient consent Participant consent was obtained verbally during the telephone interview process.

  • Ethics approval All waves of the study have received ethical approval from the relevant institutional review or research ethics committees at The Cancer Council Victoria (Australia), Roswell Park Cancer Institute (USA), University of Waterloo (Canada) and University of Strathclyde (UK).

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