A recent appellate court ruling has vacated the FDA's Final Rule that implemented the 2009 Family Smoking Prevention and Tobacco Control Act (FTA) requirement of graphic warning labels (GWLs) on cigarette packs. According to the FTA, the GWLs are to include one of nine mandatory textual warnings and a picture illustrating the negative health effects of smoking. The court decided that the GWLs selected by the FDA infringed on the tobacco company plaintiffs' First Amendment rights. The court opined that FDA's evidence of effectiveness of GWLs in general and GWLs producing strong emotional arousal in particular was insufficient to justify the infringement. Specifically, the court noted te lack of data supporting the effectiveness of GWLs in reducing actual smoking. The ruling highlights the limitations of existing data on GWLs that have been obtained predominantly through large-scale surveys using self-report outcome measures. In addition, the ruling has touched on a more basic controversy on the mechanisms underlying the effectiveness of strongly salient format and content in persuasive health communications. This project will take a unique trans- disciplinary approach to address this issue from both a clinical and neurophysiological perspective. We shall use biochemical (urine cotinine levels) and neuroimaging (Functional Magnetic Resonance Imaging, fMRI) assays, as well as traditional measures of persuasion, to compare the brain and bio-behavioral (urine cotinine) impact of GWLs that were rated high or low on the emotional response (ER) scale, used by the FDA to select GWLs for its Final Rule. We shall study 150 non-treatment seeking smokers' brain response to GWLs and monitor their urine cotinine levels, before and after a 4-week long exposure to real-life cigarette packs carrying High or Low ER GWLs. Based on our preliminary data, we hypothesize that smokers exposed to high ER GWLs will exhibit larger reductions in UC than those exposed to low ER GWLs. Based on our preliminary data and prior literature pointing to the mPFC and the amygdala as key opponent brain regions mediating the brain response to audio-visual anti-smoking ads, we hypothesize that acute exposure to high ER GWLs will be associated with higher amygdala and mPFC response than low ER GWLs. In addition, we predict that the amygdala response to GWLs will decline after 4-week long naturalistic exposure to GWLs, while mPFC response will increase, with both effects more prominent in the High ER group. Secondary hypotheses will evaluate the predictive value of acute mPFC response on urine cotinine levels change, as well changes in cigarette craving, daily intake, and brain fMRI response to visual cigarette cues prior to and after the 4-week exposure period. By applying measures of brain (fMRI), behavior (cotinine levels), persuasion and motivation (attitudes and intentions towards smoking quitting) to a cohort of smokers exposed to different affective levels of GWLs in a real-life setting, the project will provide integrated results that would complement existing population-level data and inform science-driven regulation of cigarette packaging that balances constitutional law and public health interest.

Public Health Relevance

A recent court ruling vacated the FDA Final Rule that implemented the provision of the 2009 Family Smoking Prevention and Tobacco Control Act requiring graphic warning labels on cigarette packages, citing a lack of objective evidence of their public health benefits. This project will apply a biochemical measure of tobacco consumption, neuroimaging and cognitive measures of persuasion and emotional response to a cohort of smokers exposed to graphic cigarette warning labels in a naturalistic setting. The outcome will provide integrated data that will inform science-driven regulation of cigarette packaging that balances constitutional law and public health interest.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
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Study Section
Special Emphasis Panel (ZRG1)
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Kautz, Mary A
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University of Pennsylvania
Schools of Medicine
United States
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