Article Text

Download PDFPDF
Educational differences in the impact of pictorial cigarette warning labels on smokers: findings from the International Tobacco Control (ITC) Europe surveys
  1. Gera E Nagelhout1,2,
  2. Marc C Willemsen1,2,
  3. Hein de Vries1,
  4. Ute Mons3,4,
  5. Sara C Hitchman5,6,
  6. Anton E Kunst7,
  7. Romain Guignard8,
  8. Mohammad Siahpush9,
  9. Hua-Hie Yong10,
  10. Bas van den Putte11,12,
  11. Geoffrey T Fong13,14,
  12. James F Thrasher15,16
  1. 1Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands
  2. 2Dutch Alliance for a Smokefree Society, The Hague, The Netherlands
  3. 3Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
  4. 4Unit Cancer Prevention, German Cancer Research Center (DKFZ), Heidelberg, Germany
  5. 5UK Centre for Tobacco and Alcohol Studies (UKCTAS), London, UK
  6. 6Department of Addictions, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
  7. 7Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
  8. 8French Institute for Health Promotion and Health Education (INPES), Saint-Denis, France
  9. 9Department of Health Promotion, Social and Behavioral Health, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
  10. 10VicHealth Centre for Tobacco Control, The Cancer Council Victoria, Carlton, Victoria, Australia
  11. 11Department of Communication, University of Amsterdam (ASCoR), Amsterdam, The Netherlands
  12. 12Trimbos Institute, Netherlands Institute for Mental Health and Addiction, Utrecht, The Netherlands
  13. 13Department of Psychology, School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  14. 14Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  15. 15Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, South Carolina, USA
  16. 16Department of Tobacco Research, Mexican National Institute of Public Health, Cuernavaca, Mexico
  1. Correspondence to Dr Gera E Nagelhout, Department of Health Promotion, Maastricht University (CAPHRI), P.O. Box 616, Maastricht 6200 MD, The Netherlands; Gera.Nagelhout{at}


Objective To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers’ educational level.

Methods Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.

Findings Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).

Conclusions The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.

  • Socioeconomic status
  • Packaging and Labelling
  • Public policy

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.