This study is the first to specifically evaluate how adult U.S. smokers view graphic warning labels in cigarette advertising, in conjunction with how these viewing patterns affect ability to recall the warning label content. Recall was significantly greater for the graphic warning labels compared to the text-only labels, which is consistent with findings of increased knowledge of cigarette smoking risks in countries where graphic warning labels are employed.8
As noted in Hammond et al.,8
knowledge can arise from several sources, and free or unprompted recall likely has a higher threshold for assessing risk perception than other common measures. Therefore, the authors interpret the high (83%) recall of warning label text in the graphic condition with enthusiasm. It is relatively challenging to correctly respond to this recall item, yet smokers were very capable of doing so in the Graphic as opposed to the Text condition (50%). This clearly demonstrates the effectiveness of, and support for, implementing graphic warning labels into cigarette advertisements and packaging in the U.S.
This study also provides valuable insight into how
the warning labels may be effective, which may serve to create more effective warning labels in the future. The Text condition warning label was not recalled correctly as frequently as that in the Graphic condition, and viewing patterns suggest that viewing duration across the whole advertisement and fewer fixations on the largest text (i.e., the brand name) were weakly associated with recall. Comprehension of reading text alone is often associated with viewing time and fixations24
and is consistent with the current results. In contrast, the Graphic condition warning label area quickly drew attention and held attention, relative to that in the Text condition, and these measures were associated with correct recall.
One potential explanation for the findings is the possibility that smokers were already familiar with the text in the Text condition and therefore spent less time inspecting it. However, this would not explain why they could not recall the text as well as those in the Graphic condition. Further, total time spent viewing the warning in the Text condition did not correlate with recall, whereas it did in the Graphic condition. This finding is consistent with research indicating that pictorial information that serves to complement textual information enhances memory for the text.6
This is an important feature of graphic warnings that can make them more effective than the text-only warnings that are currently employed in the U.S.
Results from this study provide important policy information regarding the development of future warning labels. Time to first viewing is associated with attention, and in the case of a cigarette advertisement, attracting attention to a health warning may be important because it distracts from viewing other parts of the advertisement. Prior research has shown that the body of a cigarette advertisement can alter smokers’ risk perceptions of a cigarette product using explicit and implicit manipulations.26
The current study demonstrates that drawing attention to the warning label can improve recall of health-relevant information, which may extend to improving risk perception of smoking. Additionally, attracting attention to the warning prior to viewing the advertisement body may change the framing of the message in the advertisement body, causing viewers to approach it with greater caution. Finally, time to first viewing has good application to real-world settings where people may allocate only a few seconds to a print advertisement. Further study on the size, font, color and location of text may identify the most effective way to draw attention.
Considerable research exists on how smokers rate graphic labels for acceptance, vividness, and ability to evoke strong emotional responses.6, 27
In general, U.S. smokers are accepting of the images, which have considerably less gore than graphic warning labels used in other countries. As noted by Dr. Lawrence Dayton, MD, Director of the FDA’s Center for Tobacco Products, “sometimes the images that work best are the ones that people can look at and have an emotional impact but not dismiss”. 28
This study empirically supports that claim: as viewing duration of the graphic image increases, the likelihood of correct recall increases. The use of this specific graphic image in the warning label increased the ability of smokers to recall the health message due to their viewing duration.
An unexpected finding was that being a Marlboro smoker was significantly associated with being less likely to correctly recall the Graphic condition warning label (75% vs 88%). This could potentially be attributable to Marlboro smokers viewing images relevant to their preferred brand more, or the warning area less, than smokers of other brands. The former possibility supports banning advertisement content, as some have proposed, including plain or blank packaging, 15, 29
while the latter suggests that regulating the body of the advertisement to include health-related information might be an effective strategy since this area is being viewed more attentively. The study was not designed or powered to properly test this empirical question, but it certainly deserves consideration and could inform regulatory stakeholders. Further research should also consider how brand-switching affects risk knowledge and perception, as well as how those contemplating trying cigarette smoking view and understand cigarette advertisements and warning labels.
The current study does have a few limitations. Recall occurred within only a few minutes after viewing the advertisement, and future work on graphic warning labels should include the effect that chronic exposure to graphic warning labels has on long-term recall, changes in attitude toward smoking, and changes in behavior, such as increased smoking-cessation attempts -- similar to effects reported by Hammond et al., 7, 8
after the introduction of graphic warning labels.
However, Hammond et al.7
did observe high correct recall and depth of processing, and the latter was associated with intention to quit, supporting the usefulness of short-term recall. Further, short-term recall was assessed in a recent experimental study of graphic cigarette warning labels, in addition to recall after 1 week, cognitive and emotional reactions,23
and results suggest a similar trend in relation to the recall items. As noted by Nonnemaker et al.,23
immediate responses (i.e., emotional and recall) likely influence short-term responses (i.e., 1-week recall, attitudes) which eventually lead to changes in quitting intentions and not starting to smoke.
Also, the warning areas were different between conditions: 123,246 vs 62,622 pixels, 16 vs 13 words, and greater text size for the Graphic and Text conditions, respectively. Therefore, group comparisons must be interpreted with caution. However, the warning labels were sized to currently mandated format for the Text condition, and pending required size for the Graphic condition; thus, results convey important policy-relevant information. Clearly, evaluation of several types are necessary to elucidate themes or styles that are most effective, as has been done with anti-smoking public service announcements.30–32
Results from this study demonstrate the effectiveness of graphic warning labels in cigarette advertisements in increasing recall of warning label–based smoking risks, and provide novel objective evidence that smokers’ viewing patterns of cigarette advertisements containing graphic warning labels are associated with recall. Graphic warning labels should be incorporated into cigarette advertisements without delay; not doing so only prolongs an overdue, necessary improvement to U.S. tobacco control.