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‘If I hadn’t seen this picture, I'd be smoking’—perceptions about innovations in health warnings for cigarette packages in Brazil: a focus group study
  1. Cristina de Abreu Perez1,
  2. Luiz Antonio Bastos Camacho1,
  3. Felipe Lacerda Mendes2,
  4. Andre Luiz Oliveira da Silva3,
  5. Valeska Carvalho Figueiredo4,
  6. Gloria Maria de Oliveira Latuf3,
  7. Ana Marcia Messeder Sebrao Fernandes3,
  8. Patrícia Gonçalves Duarte Albertassi3,
  9. Patricia Aleksitch Castello Branco3,
  10. Patricia Francisco Branco3,
  11. Stefania Schimaneski Piras3,
  12. Maribel Carvalho Suarez5
  1. 1 National School of Public Health Sérgio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
  2. 2 Conicq's Executive Secretariat, National Cancer Institute, Rio de Janeiro, Brazil
  3. 3 Brazilian Health Regulatory Agency, Rio de Janeiro, Brazil
  4. 4 Center for Studies on Tobacco and Health. National School of Public Health Sérgio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
  5. 5 Coppead, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
  1. Correspondence to Dr Cristina de Abreu Perez, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro 21040-360, Brazil; cristinadeabreuperez{at}


Objective To investigate the perceptions of young people and adults, smokers and non-smokers about the current set of innovations introduced in 2018 into the Brazilian tobacco products’ health warnings.

Methods Twenty focus groups were conducted in five state capitals in Brazil. The participants (n=163) were segmented by smoking status, age (15–17 years, 18–55 years) and social grade (C, D–E classes) to examine cigarette packaging and explore the participants’ perceptions of health warnings.

Results Health warnings capture attention, eliciting apprehension, fear, disgust and concern about the negative consequences of cigarette consumption. The 2018 Brazil health warnings are spontaneously recalled by participants, even without the presence of cigarette packages. However, the analysis also reveals the challenges of overcoming communication barriers and distorted interpretations, especially among smokers. The inclusion of direct and provocative stimuli, such as the use of the word ‘you’, attracts attention and creates more proximity to the recipient of the message. The results also highlight the interest and fear elicited by warnings on toxic constituents and the importance of using contrasting colours in warnings, which differentiate them from the colours of cigarette packs.

Conclusion Introducing innovative components in health warnings can catch consumers’ attention but considering that the interviewees encountered difficulties interpreting textual warnings about toxic constituents in cigarettes, the study reinforces the importance of adopting direct language and pictures, instead of text, which can visually transmit the warning messages and the use of specific wording that generates proximity between the emitter and receiver.

  • packaging and labelling
  • advertising and promotion
  • denormalisation
  • prevention

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Funding This paper was supported by the National Health Surveillance Agency through the Pan American Health Organization (PAHO).

  • Disclaimer This paper represents solely and exclusively the opinion and thinking of the authors, based on the evidence available at the time. It does not represent ANVISA, FIOCRUZ, Ministry of Health and the Brazilian Government’s institutional views, policies or opinions.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.