Effect of Exposure to Graphic Warning Labels on Cigarette Packages on Implicit and Explicit Attitudes toward Smoking among Young Adults

background: Research on the impact of the U.S. Food and Drug Administration’s proposed graphic warnings for cigarette packages have relied primarily on self-reported explicit outcome measures. However, studies of dual process models have shown that both conscious, controlled, reflective processes (such as explicit attitudes) and automatic associations that may be beyond conscious awareness (such as implicit attitudes) are important predictors of addictive behaviors like cigarette smoking. This study tested the effect of exposure to the FDA’s proposed graphic health warnings for cigarette packages on implicit and explicit attitudes toward smoking in a diverse sample of young adults.

methods: A two-session web-based study was conducted with 18-25 year olds (N=2192). During the first session, demographics, smoking behavior, and baseline implicit and explicit attitudes toward smoking were assessed. The second session contained random assignment to viewing one of three sets of cigarette packages, (1) packages with the proposed graphic image plus text warning, (2) packages with the text warning only, or (3) packages with the current U.S Surgeon General’s warning, and post-exposure measures. ANCOVAs were conducted to test the effect of package condition on implicit and explicit attitudes toward smoking, controlling for baseline attitudes.

results: Current smokers who viewed the packages with graphic images plus text warnings demonstrated more negative implicit attitudes toward smoking compared to smokers in the other two package conditions. Smokers and non-smokers who viewed the packages with graphic images plus text warnings or the packages with text warnings only demonstrated more negative explicit attitudes toward smoking compared to those who viewed packages with the current U.S. Surgeon General’s warning.

conclusions: The graphic health warnings were the most effective in influencing young adult smokers’ implicit attitudes toward smoking. Given the role that implicit attitudes play in predicting smoking behavior, this study’s findings have policy implications.