The Family Smoking Prevention and Control Act gave the Food and Drug Administration (FDA) the authority to regulate tobacco products, including the requirement that cigarette packages and advertisements have larger, more visible graphic health warnings. Graphic warning labels have proven to be effective in eliciting negative responses to smoking, increasing reported intention to quit smoking, and modifying beliefs about the dangers of smoking. However, much of this research was conducted at the population level when countries introduced graphic warnings, and therefore potentially confounded by concurrent tax increases and media campaigns. Further, this research is unable to detect what aspects of graphic warning labels make them effective. An important first step in evaluating effectiveness of a graphic warning label is to demonstrate if smokers can correctly recall its content. Recent eye tracking research in my laboratory has reported that how quickly one attends to the text in the label and for how long they dwell, or view, the image, is positively associated with correct recall of the graphic warning label. A subsequent study finds that graphic warning labels with a congruent message, such that the image and text convey a similar health message, elicit greater recall than incongruent graphic warning labels~ and, eye tracking patterns are more focused and defined when viewing congruent labels, and are associated with correct recall. The proposed study will randomize current daily smokers to one of the 9 FDA-approved graphic warning labels, paired with a text warning that is congruent or incongruent. Participants will have their eye tracking assessed during the initial exposure to the graphic warning label, then be provided with their own brand cigarettes with the same graphic warning label applied to their packs. Smokers will be monitored for the next 10 days, attending laboratory visits every 3 days, where they will complete measures of recall, cigarette risk beliefs, attitudes and intentions to quit smoking (last day), while also tracking daily cigarette consumption and smoking topography to examine changes in smoking behaviors, and eye tracking assessments to examine viewing patterns. Results from this study will provide important empirical data to demonstrate what format features of graphic warning labels make them effective, and how viewing patterns impact effectiveness. Results will also importantly examine the relationship between recall and improved attitudes and beliefs about smoking, as well as increased intention to quit smoking and decreases in smoking behavior. These research questions are in direct response to FDA's Center for Tobacco Products Research Priorities on warning effectiveness (#41) and identifying the most effective and best communication avenues to the public (#35).

Public Health Relevance

This application is designed to provide empirical science to inform FDA on the effect graphic warning labels will have on smoking behaviors, risk beliefs, attitudes, and intentions to quit smoking. By utilizing eye tracking we will be able to elucidate what specific features, such as congruency between image and text, improve the effectiveness of graphic warning labels. We will also rigorously assess smoking behaviors by using date- specific used cigarette filter collection and smoking topography to quantify changes in smoking behaviors.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
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Special Emphasis Panel (ZRG1-HDM-Q (53))
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Kaufman, Annette R
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University of Pennsylvania
Schools of Medicine
United States
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