The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies

Soc Sci Med. 2016 Sep:164:118-129. doi: 10.1016/j.socscimed.2016.06.011. Epub 2016 Jul 13.


Objectives: Cigarette pack warnings are a tobacco control strategy used globally. To understand their impact, we systematically reviewed longitudinal observational studies examining national implementation of strengthened warnings.

Methods: We used comprehensive search procedures to identify observational studies examining the impact of strengthening cigarette pack warnings. We report longitudinal changes in knowledge, beliefs, attitudes, intentions, and behavior.

Results: We identified 32 studies conducted in 20 countries with 812,363 participants. Studies commonly examined changes from text to pictorial warnings (64%); the remainder examined strengthened text or strengthened pictorial warnings. Knowledge increased in all 12 studies that assessed it. Studies of beliefs/attitudes and intentions showed mixed results. Quitline calls increased in four of six studies, while foregoing of cigarettes did not increase. Cigarette consumption decreased in three of eight studies; quit attempts increased in four of seven studies; and short-term cessation increased in two of three studies. Smoking prevalence decreased in six of nine studies.

Conclusions: Strengthening warnings was associated with longitudinal increases in knowledge, quitline calls and reductions in smoking behavior. Strengthening warning policies should be a priority for tobacco control globally.

Keywords: Graphic; Observational; Pictorial; Smoking; Theory; Warning.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Humans
  • Intention*
  • Motivation
  • Product Labeling / methods
  • Product Labeling / standards*
  • Smokers / psychology
  • Smoking Cessation / methods*
  • Tobacco Products / adverse effects*
  • Tobacco Use / prevention & control