@article {Kaaitobaccocontrol-2020-056396, author = {Susan Cherop Kaai and Genevieve Sansone and Gang Meng and Jane Rahedi Ong{\textquoteright}ang{\textquoteright}o and Fastone Goma and Lawrence Ikamari and Anne C K Quah and Geoffrey T Fong}, title = {Quasi-experimental evaluation of Kenya{\textquoteright}s pictorial health warnings versus Zambia{\textquoteright}s single text-only warning: findings from the International Tobacco Control (ITC) Project}, elocation-id = {tobaccocontrol-2020-056396}, year = {2021}, doi = {10.1136/tobaccocontrol-2020-056396}, publisher = {BMJ Publishing Group Ltd}, abstract = {Background Population studies in mostly high-income countries have shown that pictorial health warnings (PHWs) are much more effective than text-only warnings. This is the first quasi-experimental evaluation of the introduction of PHWs in Africa, comparing the change from text-only to PHWs in Kenya to the unchanged text-only health warning in Zambia.Methods Data were from International Tobacco Control (ITC) Surveys in Kenya (n=1495), and Zambia (n=1628), cohort surveys of nationally representative samples of adult smokers in each country. The ITC Kenya Survey was conducted in 2012 and 2018 (2 years after the 2016 introduction of three PHWs). The ITC Zambia Survey was conducted in 2012 and 2014 with no change to the single text-only warning. Validated indicators of health warning effectiveness (HWIs) (salience: noticing, reading; cognitive reactions: thinking about health risks, thinking about quitting; and behavioural reactions: avoiding warnings; forgoing a cigarette because of the warnings), and a summary measure{\textemdash}the Labels Impact Index (LII){\textemdash}measured changes in warning impact between the two countries.Results PHWs implemented in Kenya led to a significant increase in all HWIs and the LII, compared with the text-only warning in Zambia. The failure to implement PHWs in Zambia led to a substantial missed opportunity to increase warning effectiveness (eg, an estimated additional 168 392 smokers in Zambia would have noticed the warnings).Conclusions The introduction of PHWs in Kenya substantially increased the effectiveness of warnings. These results provide strong empirical support for 34 African countries that still have text-only warnings, of which 31 are Parties of the Framework Convention on Tobacco Control and are thus obligated to implement PHWs.Data are available on reasonable request. Data from the International Tobacco Control Policy Evaluation (ITC) Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently sign an ITCDR Data Usage Agreement. To avoid any real, potential or perceived conflict of interest between researchers using ITC data and tobacco-related entities, no ITCDR data will be provided directly or indirectly to any researcher, institution or consultant that is in current receipt of any grant monies or in-kind contribution from any tobacco manufacturer, distributor, or other tobacco-related entity. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).}, issn = {0964-4563}, URL = {https://tobaccocontrol.bmj.com/content/early/2021/06/10/tobaccocontrol-2020-056396}, eprint = {https://tobaccocontrol.bmj.com/content/early/2021/06/10/tobaccocontrol-2020-056396.full.pdf}, journal = {Tobacco Control} }