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Tool to assess appeal–aversion response to graphic warning labels on cigarette packs among US smokers
  1. Matthew D Stone1,2,
  2. Claudiu V Dimofte3,
  3. David R Strong1,2,
  4. Adriana Villasenor1,2,
  5. Kim Pulvers4,
  6. Karen Messer1,2,
  7. John P Pierce1,2
  1. 1 Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
  2. 2 Cancer Prevention and Control Program, Moores Cancer Center, University of California San Diego, La Jolla, California, USA
  3. 3 Department of Marketing, San Diego State University, San Diego, California, USA
  4. 4 Department of Psychology, California State University San Marcos, San Marcos, California, USA
  1. Correspondence to Dr Matthew D Stone, Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA; m3stone{at}


Introduction Graphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal–aversion assessment tool to help regulators choose among graphic packaging options.

Methods After familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal–aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017–2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated.

Results Among purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=−US$2.53, 95% CI: −US$2.76 to −US$2.31; teeth damage=−US$2.90, 95% CI: −US$3.17 to −US$2.63; and gangrenous foot=−US$3.70, 95% CI: −US$4.01 to −US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal–aversion valuations were moderated by sex, income and nicotine dependence (p<0.05).

Conclusions Smokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal–aversion tool could be useful for regulators to differentiate between graphic warning labels.

  • packaging and labelling
  • price
  • addiction

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors DRS and JPP: co-principal investigator’s responsible for the study and data collection. MDS, CVD, DRS and JPP: helped to conceptualise the study. MDS and CVD: conducted the analyses. MDS: prepared the tables and figures and wrote the majority of the manuscript with the help of JPP. CVD, DRS, JPP, AV, KP and KM: aided in interpreting the analysis and critically reviewed and revised the manuscript. DRS and MDS: had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the manuscript.

  • Funding This project was supported in part by National Cancer Institute Grant: R01-DA033296 and the Tobacco-Related Disease Research Program Grant: 28DT-0005.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of National Cancer Institute and the Tobacco-Related Disease Research Program.

  • Competing interests None declared.

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