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Do cigarette graphic warnings encourage smokers to attend a smoking cessation programme: a quasi-experimental study
  1. Joseph Guydish1,
  2. Barbara Tajima1,
  3. Thao Le1,
  4. Catherine Henderson1,
  5. Deborah Yip1,
  6. Valerie Gruber2,
  7. Wayne Garcia3,
  8. Kevin L Delucchi2
  1. 1 Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
  2. 2 Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
  3. 3 HealthRight 360, San Francisco, California, USA
  1. Correspondence to Dr Joseph Guydish, Professor of Medicine and Health Policy, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St. Ste. 265, San Francisco, CA 94118, USA; joseph.guydish{at}


Objective This study assessed whether exposure to cigarette graphic warning labels (GWLs) increased attendance to a smoking cessation programme.

Method From 2014 to 2016, alternating cohorts of smokers in 3 residential drug treatment programmes received either GWLs (experimental) or transparent (control) labels placed on their cigarette packs for 30 days. The primary outcome was the proportion of participants who chose to attend a smoking cessation group after the labelling period.

Results The sample (N=601) was 72.6% male, with a mean age of 41.9 (SD=11.16) and included African-American (37%), White (29.4%) and Hispanic (19.6%) participants. While similar on most measures, controls were more likely to be married, had been in the treatment programme longer and registered higher on expired carbon monoxide (CO). After labelling, the proportion attending at least one cessation group was 26% in the experimental condition and 18.8% among controls. In an intent-to-treat analysis adjusting for group differences at baseline, and for 2 levels of nesting, those who received GWLs were more likely than controls to attend the smoking cessation group (OR=1.58, 95% CI 1.02 to 2.44).

Conclusions Smokers who received GWLs on their cigarette packs were more likely to attend a cessation programme. Thus, this study is one of the first to document a change in a directly observed behavioural outcome as a function of month-long exposure to cigarette pack GWLs.

  • Packaging and Labelling
  • Public policy
  • Advertising and Promotion

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  • Contributors JG conceptualised the study, led the study team and drafted the paper. BT managed research operations on a day-to-day basis, and TL conducted data analyses. CH and DY conducted research activities in the participating treatment programmes, and supported literature review. VG conducted tobacco cessation groups in the clinic settings and trained other cessation group leaders. WG oversaw research efforts on behalf of HealthRight 360, and KLD provided statistical guidance. All authors participated in drafting, reviewing and revising the manuscript.

  • Funding This work was supported by NCI/FDA P30 CA082103-17S1, by the California Tobacco Related-Disease Research Program (TRDRP 22XT-0049) and by the NIDA San Francisco Treatment Research Center (P50 DA009253).

  • Competing interests None declared.

  • Ethics approval University of California San Francisco Institutional Review Board.

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