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US young adults’ perceived effectiveness of draft pictorial e-cigarette warning labels
  1. Jennah Sontag1,
  2. Michelle T Bover Manderski1,
  3. David Hammond2,
  4. Olivia A Wackowski1
  1. 1 Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey, USA
  2. 2 School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  1. Correspondence to Dr Olivia A Wackowski, Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ, USA; wackowol{at}


Significance Research shows that pictorial warning labels for cigarettes are more effective than text-only warnings, and preliminary work suggests that pictorial warnings could also be considered for electronic cigarettes (e-cigarettes). Pictorial warnings may be important for maximising their effectiveness among young people and enhancing the salience of the single nicotine addiction warning required for e-cigarettes to date in the USA. This study collected pilot data about the perceived effectiveness of draft e-cigarette pictorial warnings.

Methods Participants were 876 young adults (ages 18–29) recruited through Amazon Mechanical Turk who completed an online e-cigarette survey in 2018. Participants viewed and ranked five versions of the same e-cigarette nicotine addiction warning message—four pictorial and one text-only–on their perceived noticeability, likelihood of capturing young people’s attention, memorability, relevance to the addiction warning text and overall effectiveness in warning people about e-cigarette risks. For each outcome, presentation of the five warning versions was randomised. Pictorials included symbolic images of risk and addiction, and of priority audiences for the warning (ie, young people).

Results For all outcomes, pictorial warnings were ranked higher than the text-only warning, and the warning using a yellow triangle caution icon was ranked highest for all outcomes. The text-only warning was ranked as the least likely to be effective for all four outcomes in which it was assessed. Trends were similar for current e-cigarette users and non-users.

Conclusions Future research should assess perceptions and the appropriateness of pictorial imagery for e-cigarette warnings and test their efficacy against text-only warnings experimentally.

  • electronic nicotine delivery devices
  • packaging and labeling
  • harm reduction
  • public policy

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  • Contributors OAW designed and obtained funding for the study and contributed to data analysis and manuscript writing. JS and MTBM led the data analysis, and JS contributed to design and implementation of the study, data collection and manuscript writing. DH provided substantive input into the study design and drafts of the manuscript. All authors approved the final manuscript.

  • Funding This work was supported by a grant (K01CA189301) from the National Cancer Institute (NCI) and the Food and Drug Administration Center for Tobacco Products (FDA CTP). Contributions by OAW were also supported in part by U54CA229973 from NCI and the FDA CTP.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The Institutional Review Board at Rutgers University granted approval for the study procedures. Participants were briefed on the survey procedures, then provided online consent to begin the survey.

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