The effect of pictorial warnings on cigarette packages on attentional bias of smokers

The effects of emotional distress on attentional bias toward cigarette warnings according to smokers' anxiety levels

Anxiety is related with the substance use, including cigarette smoking. Avoidance is one of the strategies smokers with anxiety adopt to manage negative affect, which can be contradictory to a strategy of cigarette warnings that is used to induce negative affect to change smoking behaviors. Therefore, this study examined whether smokers' anxiety levels decrease their attentional biases toward cigarette warnings, especially in response to emotional distress. High-anxiety (n = 60) and low-anxiety (n = 60) smokers were randomly assigned to either a stress condition that utilized the PASAT-C task (Paced Auditory Serial Addition Task-Computer version) or a controlled condition. With the eye-tracking task that involved viewing 8 visual stimuli of cigarette packs composed of warnings and brandings, time to first fixation and fixation duration to warnings compared to brandings were measured both pre and post conditions. The results revealed that high-anxiety smokers detected warnings faster after stress conditions while low-anxiety smokers showed the consistent time to first fixation on warnings. In terms of fixation durations, high-anxiety smokers showed hypervigilance toward warnings that are considered to be a threat, but low-anxiety smokers showed avoidance under stress conditions, particularly toward social-focused warnings. These results indicate that high-anxiety smokers are more vulnerable to emotional distress and have an attentional bias toward fear appeals. Despite hypervigilance, they had greater psychological reactance toward warnings that the conflict between avoidance and hypervigilance might have contributed to, so the effectiveness of fear appeals may be limited regardless of the increased fixation duration.

The influence of price and funding source disclosure on medication labels: Implications for intended adherence, perceived value and efficacy, and feelings of burden and guilt

OBJECTIVES

To examine if informing people in free-at-the-point-of-use medical systems of the financial value of medicines, and priming them with the fact that the medication is funded by taxation, influences people's perceived value and efficacy of the medicines, feelings of burdensomeness and guilt, and intended adherence.

DESIGN

An experiment was implemented to examine the impact of medication labelling featuring the presence (vs. absence) of the phrase 'funded by UK the taxpayer' and pricing information (absent vs. £20 vs. £200) on outcome measures.

METHODS

A total of 257 UK participants (age: M = 29.10 years, SD = 9.15; 89 males, 167 females, one undisclosed) who were currently taking medication were recruited from an online participant pool (prolific academic). Participants viewed an image of a medication with the manipulated price and taxation message on the label. They then completed a number of measures to gauge perceived value and efficacy of the medicines, feelings of burdensomeness and guilt, and intended adherence.

RESULTS

Findings point to both positive and negative consequences of such labelling of medication, with the taxpayer label increasing perceptions of value but also increasing feelings of guilt. The price labels demonstrated a positive effect on perceived value and intended adherence.

CONCLUSIONS

Discussion of results is centred on potential policy implications, applied recommendations, and future directions for study.

Deliberation and Valence as Dissociable Components of Counterarguing among Smokers: Evidence from Neuroimaging and Quantitative Linguistic Analysis

Counterarguing is a key obstacle to successful persuasion. However, the difficulty of directly measuring counterarguing during message exposure limits knowledge of the underlying mechanisms. The current study combines neuroimaging and linguistic measures to unpack neurocognitive and psychological mechanisms associated with counterarguing among a sample of established smokers in response to anti-smoking messaging. We capture participants' neural activity in brain regions associated with effortful deliberation and negative argumentation during message exposure, and link it with their subsequent language patterns to further understanding of counterarguing in the brain. Greater brain activity within key regions of interest associated with deliberation and negative argumentation is associated with greater cognitive depth and less positivity in the post-scan message descriptions, respectively, among those who have lower intention to change their smoking behavior. We connect these neural representations of counterarguing with psychological theories and discuss implications that may increase the impact of persuasive communications.

Effect of magnification and changes in tobacco pictorial warning on asceticism of tobacco use: An exploratory survey

Background:

Tobacco usage-related diseases pose serious threat for not only public health but also for country's economy and warning labels are considered as an effective strategy to spread more awareness on tobacco hazards.

Aim:

The aim of this hospital-based questionnaire survey was to assess the effect of magnified pictorial warning over tobacco products on asceticism of tobacco use and to measure the association of selected tobacco habits variables and asceticism of tobacco use.

Materials and Methods:

Present exploratory survey based on triangulation method of data collection was conducted among conveniently selected 1,008 tobacco users or smokers attending OPD services at tertiary care center during the year 2018–2019. Quantitative survey data was collected through structured questionnaire and two FGDs were conducted for qualitative information. Data was analyzed using descriptive and inferential statistics.

Results:

Magnification of health warnings over tobacco packets had impact on tobacco or cigarette consumption to some extent (415; 41.25%); but insisted only one third (383; 38.0%) participants to quit tobacco use. A significant association was observed between awareness about bad effect of tobacco use and attempt of quit tobacco uses (OR 0.29; CI 95%, 0.223–0.390; P = 0.001). Furthermore, significant effect of magnified warning over tobacco products was seen on reduction in tobacco use (OR 0.39; CI 95%, 0.300–0.531; P = 0.001) and quitting the tobacco (OR 0.38; CI 95%, 0.28620.513; P = 0.001).

Conclusion:

Study results concluded that magnification of pictorial warning is associated with the asceticism of tobacco use to some extent but alone it is not sufficient. Therefore, adjunct intervention of mass public education about bad effect of tobacco use is more essential to augment asceticism of tobacco use.

[Effectiveness of cigarette-pack warning labels in capturing the attention of smokers and nonsmokersEficácia das tarjas de advertência em maços de cigarro para atrair a atenção de fumantes e não fumantes]

Objective

To determine the ability of cigarette-pack warning labels, of the minimum size required by the World Health Organization, to capture the attention of smokers and nonsmokers.

Methods

In this study, 30 smokers and 30 nonsmokers completed a dot-probe task in which they simultaneously observed images of cigarette packs split in two: the top contained the cigarette brand and the bottom contained the warning label. During the task, brain activity was recorded through two event-related potentials of the negative-polarity type--the potential that occurs in the posterior-contralateral zone approximately 200 ms after a stimulus (N2pc) and the sustained posterior contralateral negativity (SPCN) response--which are indicators of early and sustained attention.

Results

In both groups, a greater amplitude of N2pc and SPCN potentials was found for the part of the pack containing the cigarette brand. However, during the dot-probe task, reaction times were shorter for the warning label.

Conclusions

These results suggest that, initially, attention is focused on the cigarette brand, and only then on the warning label. The inability of warning labels to capture early-phase attention decreases their effectiveness, especially in smokers. We suggest that warning labels be enlarged to facilitate increased attention response.

Using Self-affirmation to Increase the Effects of Emotive Health Warnings on Smoking: A Randomized Exploratory Trial

Introduction

Emotive health messages are widely used tools in tobacco control. However, under some circumstances, they can be less effective than desired by eliciting defensive responses in smokers.

Aims

This study tests whether enhancing a currently used emotive graphic smoking health warning with a self-affirmation component reduces cigarette consumption and whether potential effects are stronger in heavier smokers, as suggested by previous research.

Methods

Participants (n = 265) were randomly allocated to a self-affirmation (reflecting on personal values and positive traits using a questionnaire) or matched control condition before viewing an emotive graphic health message from a current Australian government public health campaign. The primary outcome (cigarettes per day [CPD]) was assessed both before and a week following the intervention.

Results

No main effect of self-affirmation on smoking, but as hypothesized, a significant interaction between baseline smoking and self-affirmation was found that showed that heavier smokers (>21 CPD) who self-affirmed significantly reduced CPD compared to nonaffirmed smokers.

Conclusions

These findings support the use of self-affirmation to enhance smoking awareness campaigns in heavier smokers.

Implications

This study shows that enhancing emotive graphic smoking health messages with self-affirmation (the act of reflecting on positive aspects of oneself) increases their effectiveness in heavier smokers. This suggests that self-affirmation might be a particularly useful tool for health promotion targeting heavier smokers. This study adds to previous research in that it is the first to test the add-on effects of self-affirmation to current graphic health messages on smoking rather than smoking-related cognitions.

Systematic Review of Measures Used in Pictorial Cigarette Pack Warning Experiments

BACKGROUND

We sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments and provide recommendations for future studies.

METHODS

Our systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity.

RESULTS

We identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly used outcomes were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Of 68 studies, 37 (54%) mentioned a theory as informing the study.

CONCLUSIONS

Our review found great variability in constructs and measures used to evaluate the impact of cigarette pack pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources.

IMPLICATIONS

Robust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for standardized, theory-based measures.

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon

INTRODUCTION

Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation.

METHODS

A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview.

RESULTS

Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004).

CONCLUSION

Low-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.

Pictorial cigarette pack warnings: a meta-analysis of experimental studies

OBJECTIVE

To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings.

DATA SOURCES

We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles.

STUDY SELECTION

We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33,613) met criteria.

DATA EXTRACTION AND SYNTHESIS

Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures.

RESULTS

Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes.

CONCLUSIONS

The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

Neural correlates of cigarette health warning avoidance among smokers

BACKGROUND

Eye-tracking technology has indicated that daily smokers actively avoid pictorial cigarette package health warnings. Avoidance may be due to a pre-cognitive perceptual bias or a higher order cognitive bias, such as reduced emotional processing. Using electroencephalography (EEG), this study aimed to identify the temporal point at which smokers' responses to health warnings begin to differ.

METHOD

Non-smokers (n=20) and daily smokers (n=20) viewed pictorial cigarette package health warnings and neutral control stimuli. These elicited Event Related Potentials reflecting early perceptual processing (visual P1), pre-attentive change detection (visual Mismatch Negativity), selective attentional orientation (P3) and a measure of emotional processing, the Late Positive Potential (LPP).

RESULTS

There was no evidence for a difference in P1 responses between smokers and non-smokers. There was no difference in vMMN and P3 amplitude but some evidence for a delay in vMMN latency amongst smokers. There was strong evidence for delayed and reduced LPP to health warning stimuli amongst smokers compared to non-smokers.

CONCLUSION

We find no evidence for an early perceptual bias in smokers' visual perception of health warnings but strong evidence that smokers are less sensitive to the emotional content of cigarette health warnings. Future health warning development should focus on increasing the emotional salience of pictorial health warning content amongst smokers.

FDA cigarette warning labels lower craving and elicit frontoinsular activation in adolescent smokers

Cigarette smoking is an economically and epidemiologically expensive public health concern. Most adult smokers become addicted during adolescence, rendering it a crucial period for prevention and intervention. Although litigation claims have delayed implementation, graphic warning labels proposed by the U.S. Food and Drug Administration (FDA) may be a promising way to achieve this goal. We aimed to determine the efficacy of the labels in reducing in-scanner craving and to characterize the neurobiological responses in adolescent and adult smokers and non-smokers. While undergoing functional magnetic resonance imaging, thirty-nine 13- to 18-year-old adolescent and forty-one 25- to 30-year-old adult smokers and non-smokers rated their desire to smoke when presented with emotionally graphic warning labels and comparison non-graphic labels. Compared with adult smokers, adolescent smokers exhibited greater craving reduction in response to the warning labels. Although smokers evinced overall blunted recruitment of insula and dorsolateral prefrontal cortex (DLPFC) relative to non-smokers, an effect that was stronger in adolescent smokers, parametrically increasing activation of these regions was associated with greater craving reduction. Functional connectivity analyses suggest that greater DLPFC regulation of limbic regions predicted cigarette craving. These data underscore a prominent role of frontoinsular circuitry in predicting the efficacy of FDA graphic warning labels in craving reduction in adult and adolescent smokers.

Pictorial cigarette pack warnings: a meta-analysis of experimental studies

Objective

To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings.

Data sources

We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles.

Study selection

We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria.

Data extraction and synthesis

Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures.

Results

Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes.

Conclusions

The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

Randomized trial of telephone-delivered acceptance and commitment therapy versus cognitive behavioral therapy for smoking cessation: a pilot study

OBJECTIVE

We conducted a pilot randomized trial of telephone-delivered acceptance and commitment therapy (ACT) versus cognitive behavioral therapy (CBT) for smoking cessation.

METHOD

Participants were 121 uninsured South Carolina State Quitline callers who were adult smokers (at least 10 cigarettes/day) and who wanted to quit within the next 30 days. Participants were randomized to 5 sessions of either ACT or CBT telephone counseling and were offered 2 weeks of nicotine replacement therapy (NRT).

RESULTS

ACT participants completed more calls than CBT participants (M = 3.25 in ACT vs. 2.23 in CBT; p = .001). Regarding satisfaction, 100% of ACT participants reported their treatment was useful for quitting smoking (vs. 87% for CBT; p = .03), and 97% of ACT participants would recommend their treatment to a friend (vs. 83% for CBT; p = .06). On the primary outcome of intent-to-treat 30-day point prevalence abstinence at 6 months postrandomization, the quit rates were 31% in ACT versus 22% in CBT (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 0.7-3.4). Among participants depressed at baseline (n = 47), the quit rates were 33% in ACT versus 13% in CBT (OR = 1.2, 95% CI = 1.0-1.6). Consistent with ACT's theory, among participants scoring low on acceptance of cravings at baseline (n = 57), the quit rates were 37% in ACT versus 10% in CBT (OR = 5.3, 95% CI = 1.3-22.0).

CONCLUSIONS

ACT is feasible to deliver by phone, is highly acceptable to quitline callers, and shows highly promising quit rates compared with standard CBT quitline counseling. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed.

Smokers' and nonsmokers' beliefs about harmful tobacco constituents: implications for FDA communication efforts

INTRODUCTION

Legislation requires the U.S. Food and Drug Administration (FDA) to release information to the public about harmful constituents in tobacco and tobacco smoke. To inform these efforts, we sought to better understand how smokers and nonsmokers think about tobacco constituents.

METHODS

In October 2012, 300 U.S. adults aged 18-66 years completed a cross-sectional Internet survey. The questions focused on 20 harmful tobacco constituents that the FDA has prioritized for communicating with the public.

RESULTS

Most participants had heard of 7 tobacco constituents (ammonia, arsenic, benzene, cadmium, carbon monoxide, formaldehyde, and nicotine), but few participants had heard of the others (e.g., acrolein). Few participants correctly understood that many constituents were naturally present in tobacco. Substances that companies add to cigarette tobacco discouraged people from wanting to smoke more than substances that naturally occur in cigarette smoke (p < .001). Ammonia, arsenic, carbon monoxide, and formaldehyde being in cigarettes elicited the most discouragement from smoking. Constituents elicited greater discouragement from wanting to smoke if respondents were nonsmokers (β = -.34, p < .05), had negative images of smokers (i.e., negative smoker prototypes; β = .19, p < .05), believed constituents are added to tobacco (β = .14, p < .05), or were older (β = .16, p < .05).

CONCLUSIONS

Our study found low awareness of most tobacco constituents, with greater concern elicited by additives. Efforts to communicate health risks of tobacco constituents should consider focusing on ones that elicited the most discouragement from smoking.

Graphic imagery is not sufficient for increased attention to cigarette warnings: the role of text captions

AIMS

The present study aims to assess the extent to which attention to UK cigarette warnings is attributable to the graphic nature of the content.

DESIGN

A visual dot probe task was utilised, with the warnings serving as critical stimuli that were manipulated for the presence of graphic versus neutral image content, and the accompanying text caption. This mixed design yielded image content (graphic versus neutrally-matched images) and presence (versus absence) of text caption as within subjects variables and smoking status as a between-participants variable.

SETTING

The experiment took place within the laboratories of a UK university.

PARTICIPANTS

Eighty-six psychology undergraduates (51% smokers, 69% female), predominantly of Caucasian ethnicity took part.

MEASUREMENTS

Reaction times towards probes replacing graphic images relative to probes replacing neutral images were utilised to create an index of attentional bias.

FINDINGS

Bias scores (M = 10.20 ± 2.56) highlighted that the graphic image content of the warnings elicited attentional biases (relative to neutral images) for smokers. This only occurred in the presence of an accompanying text caption [t (43) = 3.950, P < 0.001] as opposed to when no caption was present [t (43) = 0.029, P = 0.977]. Non-smokers showed no biases in both instances.

CONCLUSIONS

Graphic imagery on cigarette packets increases attentional capture, but only when accompanied by a text message about health risks.

Comparison of craving between smoked and smokeless tobacco across a variety of cue exposures

Smokeless tobacco use is a major health issue but has received less attention in craving research. The present non-funded study aimed to assess craving associated with smokeless tobacco compared to smoked forms. Forty-eight nicotine dependent male subjects attending a deaddiction center in India were recruited. The subjects were exposed to six nicotine related and two control cues in random order for variable time durations. The urge to consume the tobacco product was rated. Tobacco-related cues produced different patterns and degrees of craving among users of smoked and smokeless tobacco. This has implications for management and drug development.

Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment

BACKGROUND

The U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups.

METHODS/FINDINGS

Participants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057).

CONCLUSIONS

Findings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities.

Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging

OBJECTIVE

Placing a combination of a written warning and a graphic image on cigarette packaging (so called "pictorial warnings") is one of the WHO Framework Convention on Tobacco Control's most controversial recommendations. Our randomized controlled trial investigated if pictorial warnings lead to significantly higher motivation to quit, as compared to written warnings alone.

METHODS

Four pictorial warnings were selected from the EU Commission's official image catalogue. Study arm 1 (44 adult smokers) viewed only the written warnings while study arm 2 (44 adult smokers) viewed the corresponding pictorial warnings. Self-affirmation was a second randomly manipulated factor, and nicotine dependence a quasi-experimental third factor. The main outcome measured was the motivation to quit, with fear intensity as one of the secondary outcomes.

RESULTS

Pictorial warnings were associated with a significantly higher motivation to quit. A pictorial warning was also associated with higher fear intensity. The effect of warnings appears to be independent of nicotine dependence and self-affirmation.

CONCLUSIONS

Nationwide implementation of pictorial warnings may be effective in increasing heavy smokers' motivation to quit.

PRACTICE IMPLICATION

Due to the fact that perceived vulnerability, response and self-efficacy are not more strongly affected by pictorial warnings this effect may turn out to be short-term.