To the authors' knowledge, there are no published evaluations of pictorial warnings in the Middle East. Given that neighboring countries are likely to embark on similar tobacco control initiatives, our results can provide insights to other tobacco control authorities in the region. For example, one of the proposed pictorials (child covering mouth) to be used in Jordan is currently being used in Egypt.
We compared four proposed pictorials to a pictorial that has been in the market for several years and whose effects have likely been exhausted. Thus, we anticipated that any new pictorial would (upon first observation) likely be perceived as more salient, adding more information, or eliciting more fear, than the previous pictorial (our baseline).
Among smokers, for most of the proposed pictorials (with the exception of the child covering mouth), the number of respondents reporting salience was comparable to the old pictorial. With regard to fear-elicitation, most respondents perceived the proposed warnings (with the exception of smoking as a prison) as fear-eliciting. Although this is a positive indication of their efficacy, it is important to point out that fear-elicitation was only reported by less than half (42%) of smoking respondents for all of the pictorials. In addition, despite being new (relative to the current pictorial), with the exception of one proposed warning (child with inhaler), perception of added information for the proposed pictorials was comparable to that of the old warning. Furthermore, despite more reported motivation to quit smoking after viewing the new pictorials, the overall proportions reporting motivation to quit were generally low.
Among nonsmokers, respondents expressed higher perceptions of salience and fear elicitation when viewing the new pictorials compared with the existing warning. These results are consistent with previous research indicating that health warnings are more salient among non-smokers [1
]. However, with the exception of one proposed warning (child with inhaler), perception of added information for the proposed pictorials was comparable to that of the old warning. Also, respondents reporting motivation not to initiate smoking were comparable after viewing the new warnings and the old pictorial. These results imply that if stronger motivation or added information among nonsmokers is desired from these new pictorials, they may need to be revised.
Our data suggest that the proposed pictorials may not trigger sufficient perceptions of salience (particularly for smokers) and added information for either smokers or nonsmokers. Thus, Jordan may benefit from specifically introducing more graphic and informative pictorials, in line with the general international consensus. Previous research suggests combining graphic warnings with supportive cessation information (which was not available in any of the proposed warnings) [1
]. Jordan also might benefit from selecting a larger group of pictures to address various specific elements of perception, given that it is difficult to capture all elements in one pictorial warning and that the effects of fewer pictorials can be quickly exhausted [17
]. Furthermore, the variability in response across pictorials and by smoking status emphasizes the need for carefully selecting and using various pictorials that can resonate across a diverse audience, since the intended audience will vary in age, levels of literacy, socioeconomic status, and smoking status. For example, in our study, some respondents indicated that messages containing children did not sufficiently express the dangers of smoking to smokers, and did not seem relevant to young adults who do not have children. FCTC guidelines also have pointed to the need for careful consideration of literacy when choosing the pictorial warnings [17
Finally, with regards to activities that could improve public perception regarding tobacco, supplementary educational campaigns can be useful, particularly after observing the low proportion of respondents reporting added knowledge after viewing the pictorials and text. Such campaigns can also address waterpipes, given that the latter are a common form of tobacco with fewer control measures (the proposed pictorial warnings only apply to cigarette packages). It is also recommended that Jordan strengthens its document research on the tobacco industry in order to gather information regarding the messages being sent and the groups being targeted in the country by tobacco industry advertising. Accordingly, the Ministry of Health can ensure that the information conveyed by the pictorial warnings counters these messages effectively. Document research in other countries has provided important information to strengthen the impact of the tobacco control policies on smoking initiation and cessation [27
Our study had some limitations: we used a convenience sample of youth, which is not representative of the final target audience for the proposed pictorials. Thus, similar surveys of other demographic groups can better inform decision-makers of the usefulness of the warnings. The study is also cross-sectional in design and does not capture temporal changes that may occur after prolonged observation of the pictorial warnings. Population-based monitoring over time would be needed to better understand the impact of warnings. Nevertheless, more provocative pictorials may have elicited stronger responses than those observed in our sample.