The US Food and Drug Administration (FDA) now has regulatory authority over tobacco, including the selection and changing of pictorial and textual content for health warning labels (HWLs) on cigarette packaging. In September 2012, the US is scheduled to implement nine different text messages and images on HWLs that will cover 50% of the front and back of cigarette packs. After the first round of pictorial HWLs is implemented, its effects will wear out over time. The FDA is charged with changing the content of HWLs if they have evidence that changing them will ...promote greater public understanding of the risks associated with the use of tobacco products.'' The proposed study will address methodological shortfalls of previous studies to provide researchers and US regulators with state-of-the-art scientific evidence on the effects of key pictorial HWL policy characteristics on smokers' understanding of smoking-related risks and on smoking cessation. The results will inform legal challenges to implementation of current US policy, and they will provide the basis for decision-making about future pictorial HWL policy in the US and around the world. We propose to conduct studies of adult smokers in the US and in three comparable countries that will all implement new pictorial HWLs in 2012, but with policies that differ from one another in important ways: 1. the US will implement its 1st round of pictorial HWLs, using short and simple risk messages; 2. Mexico will rotate new HWLs at the highest frequency in the world (i.e., two new HWLs every three months); 2. Canada will implement its 2nd round of pictorial HWLs, which include comprehensive risk and quit messages; 4. Australia will implement its 2nd round of pictorial HWLs, while also implementing the innovative policy of prohibiting brand colors and logos from cigarette packages in order to enhance the efficacy of HWLs. This project will capitalize on the unprecedented opportunity to systematically examine the real world effects over time of different pictorial HWL policies that US regulators should consider for future policy development. The proposed project will pursue the following specific aims:
Specific Aim 1 : We will use a quasi-experimental design with panels of adult smokers in four countries (Canada, Australia, Mexico, United States) to determine which pictorial HWL characteristics most effectively promote understanding of smoking-related risks and increase cessation behavior.
Specific Aim 2 : We will conduct a series of controlled randomized experiments among adult smokers in the same four countries, systematically varying their exposure to pictorial HWL characteristics that are novel relative to existing HWLs, in order to determine the cognitive and affective impact of these manipulations. Meeting these aims will produce the scientific evidence that US regulators need on the real world impacts of different pictorial HWL policy options. Results will be disseminated to researchers and decision-makers, including the FDA, which can revise US HWLs to improve consumer understanding of smoking-related harms.

Public Health Relevance

In 2012, the United States (US) will implement prominent pictorial health warning labels (HWLs) on cigarette packaging in order to reduce tobacco use, which is the leading cause of preventable death in the US. The proposed study will examine the effects and wear out of this policy, comparing the results with those from three other countries (i.e., Canada, Australia, and Mexico) whose pictorial HWL policies contrast with US policy in important ways. Results from this research will increase understanding of the characteristics of pictorial HWL policies that are most effective and sustainable, so that regulators in the US and other countries can design HWL policies that better address the substantial public health burden of tobacco use.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
Project #
Application #
Study Section
Community Influences on Health Behavior (CIHB)
Program Officer
Vollinger, Robert
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of South Carolina at Columbia
Public Health & Prev Medicine
Schools of Public Health
United States
Zip Code
Anshari, Dien; Yong, Hua-Hie; Borland, Ron et al. (2018) Which type of tobacco product warning imagery is more effective and sustainable over time? A longitudinal assessment of smokers in Canada, Australia and Mexico. BMJ Open 8:e021983
Cho, Yoo Jin; Thrasher, James F; Swayampakala, Kamala et al. (2018) Does Adding Information on Toxic Constituents to Cigarette Pack Warnings Increase Smokers' Perceptions About the Health Risks of Smoking? A Longitudinal Study in Australia, Canada, Mexico, and the United States. Health Educ Behav 45:32-42
Thrasher, James F; Brewer, Noel T; Niederdeppe, Jeff et al. (2018) Advancing Tobacco Product Warning Labels Research Methods and Theory: A Summary of a Grantee Meeting Held by the US National Cancer Institute. Nicotine Tob Res :
Swayampakala, Kamala; Thrasher, James F; Yong, Hua-Hie et al. (2018) Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia. Nicotine Tob Res 20:888-896
Salloum, Ramzi G; Louviere, Jordan J; Getz, Kayla R et al. (2018) Evaluation of strategies to communicate harmful and potentially harmful constituent (HPHC) information through cigarette package inserts: a discrete choice experiment. Tob Control 27:677-683
Thrasher, James F; Islam, Farahnaz; Davis, Rachel E et al. (2018) Testing Cessation Messages for Cigarette Package Inserts: Findings from a Best/Worst Discrete Choice Experiment. Int J Environ Res Public Health 15:
Cho, Yoo Jin; Thrasher, James F; Yong, Hua-Hie et al. (2018) Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Soc Sci Med 197:226-234
Lindblom, Eric N; Berman, Micah L; Thrasher, James F (2017) FDA-Required Tobacco Product Inserts & Onserts–and the First Amendment. Food Drug Law J 72:1-25
Cole, Casey A; Anshari, Dien; Lambert, Victoria et al. (2017) Detecting Smoking Events Using Accelerometer Data Collected Via Smartwatch Technology: Validation Study. JMIR Mhealth Uhealth 5:e189
Kollath-Cattano, Christy; Osman, Amira; Thrasher, James F (2017) Evaluating the perceived effectiveness of pregnancy-related cigarette package health warning labels among different gender/age groups. Addict Behav 66:33-40

Showing the most recent 10 out of 31 publications