Skip to main content
Download PDF

Responses to textual and pictorial cigarette pack health warnings: findings from an exploratory cross-sectional survey study in Austria

BMC Public Health volume 18, Article number: 442 (2018) Cite this article

Abstract

Background

Packaging and labelling tobacco products has emerged as an effective policy to reduce the global health burden of tobacco use. The main purpose of this study was to explore Austrian smokers’ and ex-smokers’ responses to both the textual and pictorial cigarette pack health warnings (CPHWs) recently implemented.

Methods

We analysed self-reported data (N=500) from an Austrian cross-sectional survey that was conducted after the implementation of the new pictorial CPHWs in 2016.

Results

The results showed only weak effects of the CPHWs on the decision to quit or reduce smoking, and the level of impact of the CPHWs remained limited particularly because of smokers denying the ill-effects of tobacco use.

Conclusions

Although the CPHWs seem to have the potential to promote a change in smoking behaviour, the warnings reached only a rather small group of smokers, while the majority of smokers appeared to remain unaffected by this intervention. Public health policies are challenged to increase the salience of CPHWs and to overcome smokers’ denial of detrimental health effects.

Peer Review reports

Background

Despite recent declines in smoking prevalence in a majority of countries worldwide [1], smoking still represents a major public health concern. The World Health Organisation (WHO) estimated the global proportion of all deaths attributable to tobacco use to be 12 % among adults aged 30 years or over [2].

In recognition of the global health burden of tobacco use, the WHO Framework Convention on Tobacco Control (FCTC) has been adopted, prompting the participating nations to implement a set of tobacco control policies. One of these policies concerns packaging and labelling: each tobacco product must carry clear, visible and legible health warnings on the package (Article 11) [3]. This policy has emerged as a cost-effective intervention when it comes to communicating the health risks of smoking to a broad audience of smokers [4].

To date, 181 countries are parties to the FCTC, and the Austrian government ratified this convention in 2005. In accordance with the FCTC and with European guidelines (see Tobacco Products Directive 2014/40/EU) [5], the revised version of the Austrian Tobacco Act [6] requires each tobacco product to carry (1) a general textual warning (“Smoking kills – quit now.”), (2) a general message (“Tobacco smoke contains more than 70 substances that have been proved to be carcinogenic.”), and (3) a combination of an additional textual warning (e.g., “Smoking damages your lungs.”) with a matching picture showing the health effects caused by smoking. These cigarette pack health warnings (CPHWs) are required to cover 65% of each the front and rear side of the tobacco product.

A number of smokers’ responses to CPHWs have been documented in previous studies, and pictorial warnings have been found to be more effective in terms of provoking cognitive, emotional, and behavioural reactions than text-only warnings [4, 7–10]. In general, CPHWs have been shown to generate knowledge and reflection about the health risks of smoking [7, 10, 11]; to reduce the odds of starting to smoke in adolescence [12]; and to increase the likelihood of avoiding cigarettes, making attempts to quit, or actually quitting smoking [11, 13, 14].

Comparable data for Austria after implementation of the new CPHWs in 2016 are however lacking. The main objective of this study thus was to explore smokers’ responses to both textual and pictorial CPHWs and to analyse how these responses were related to intentions to quit smoking.

Methods

Study design and data

The present study is based on survey data concerning smoking behaviour and responses to CPHWs. Data was collected from February to March 2017 by The Institute for Empirical Social Studies (IFES) on behalf of the authors. A random sample of 500 persons was drawn from the Austrian population of both current smokers and ex-smokers (i.e. smoking cessation during the last 12 months). Given that smoking usually develops in the period from adolescence to young adulthood [15] and that an early onset of smoking is strongly related to future smoking patterns [16, 17], smoking prevention is of great public health interest among the younger age group in particular. We therefore aimed for a disproportionately higher rate of 15–23 year olds in order to increase statistical power to detect potential differences between the younger and the older age groups. Self-reported data were collected using computer-assisted telephone and web interviews (CATI/CAWI).

Measures

The conceptualization of the survey variables was largely based on previous survey studies examining the effects of CPHWs on smokers’ behaviour and intentions [7, 18–21]. The variables used in this study comprised behavioural, cognitive, and emotional responses to the CPHWs, measures of salience of the CPHWs, smokers’ assessments of the health risks of smoking, smokers’ intentions to quit, smoking history and dependence, and socio-economic and socio-demographic factors.

Smoking status

Participants were categorized according to their smoking status, i.e. to the fact whether they smoked every day (regular smokers) or occasionally (occasional smokers), or whether they were ex-smokers that had quit smoking during the last 12 months (ex-smokers).

Smoking cessation because of pictorial CPHWs

To assess the direct effects of health warnings on the decision to quit smoking, ex-smokers were asked to declare whether or not the new cigarette packs with the pictorial warnings were the main reason or at least one of the reasons why they quit smoking. Response options were: 0 =no; 1 =yes, one reason among others; 2 =yes, the main reason.

Intention to quit smoking

To quantify quitting intentions, regular and occasional smokers (but not ex-smokers) were asked how strongly they wanted to quit smoking. Response categories were: 0 =not at all; 1 =somewhat; 2 =quite a lot; 3 =a lot. In order to facilitate interpretability in subsequent regression analysis, we dichotomized this variable by combining response categories 1, 2, and 3. The resulting categories thereby represented no intention to quit smoking on the one hand, and at least a slight intention to quit smoking on the other hand.

Warnings impact score (WIS)

In order to obtain a total score for the impact of textual and pictorial health warnings, we summed up the dichotomized scores of four items (for a similar approach see [20]):

  1. 1

    Change in feelings because of the new CPHWs: Regular and occasional smokers were asked whether or not the new CPHWs had changed their feelings about smoking. Response options were: 0 =no, feelings have not changed; 1 =yes, I feel bad smoking; 2 =yes, I feel very bad smoking. We dichotomized this item score by combining response categories 1 and 2 into one category.

  2. 2

    Forgoing cigarettes because of pictorial CPHWs: Regular and occasional smokers were asked to specify whether or not they had reduced cigarette consumption due to the pictures on the packs. Response categories were: 0 =no; 1 =yes, I smoke a little less; 1 =yes, I smoke much less. Again, we combined response categories 1 and 2 to dichotomize this item score.

  3. 3

    Frequency of reading warnings: Regular and occasional smokers were requested to indicate how often they had read the textual warnings on the cigarette packs during the last weeks. Response categories were: 0 =never; 1 =once; 2 =repeatedly; 3 =often; 4 =almost always. For dichotomization, we combined response categories 0–1 and 2–4 into one category, respectively.

  4. 4

    General attitude toward pictorial warnings: Regular and occasional smokers were asked whether or not they would agree that it is generally a good idea to show pictorial warnings on the cigarette packs as a deterrent (0 =no; 1 =yes).

Higher values on the WIS represented more positive responses in terms of provoking the effects intended by the health warnings. This sum score was then used in regression analysis. Confirmatory factor analysis confirmed the one-dimensional structure of this scale, and internal consistency was sufficient (Cronbach’s α=0.75).

Assessment of the validity of warnings

Regular and occasional smokers were requested to state whether they believed that the warnings on the cigarette packs are valid, on a 7-point rating scale ranging from 1 =very untrue of what I believe, to 7 =very true of what I believe.

Smoking risk assessment

To quantify smokers’ knowledge about the health risks of smoking, regular and occasional smokers were requested to assess (1) smokers’ risk (compared to non-smokers of the same age and sex) to develop a life-threatening disease, (2) smokers’ risk to develop a life-threatening disease while they keep smoking, and (3) smokers’ risk to die earlier than if they quit smoking. Response categories ranged from 1 =my risk is much lower to 7 =my risk is much higher for the first item and from 1 =very low to 7 =very high for the latter two items, on a 7-point Likert-scale, respectively. We summed up the three item scores and used the resulting sum score in a subsequent analysis. Internal consistency was found to be good (Cronbach’s α=0.86).

Use of neutral covers

Regular and occasional smokers were asked to indicate whether or not they used a neutral cover to hide the pictures on the cigarette packs (0 =no; 1 =yes).

Cigarette dependence

The measure for cigarette dependence was based on the score used in the Fagerström Test for Cigarette Dependence (FTCD) [22, 23]. Internal consistency was found to be good in the present study (Cronbach’s α=0.82). Again, these test items were only presented to regular and occasional smokers.

Additional variables

Both the responses to the CPHWs and the intentions to quit smoking may be affected by individual-level differences in factors such as smoking history and socio-demographic/socio-economic backgrounds [10, 20, 24, 25]. We thus considered the number of years smoking (≤3 years; 4–10 years; >10 years), household income (≤2000 Euros; 2001–3000 Euros; >3000 Euros), educational level (highest level reached: still in school or compulsory education; apprenticeship certificate or diploma from vocational school; high school diploma; university degree); age group (15–23 years vs. >23 years), and sex (male vs. female).

Statistical analysis

First, descriptive analyses were used to explore the sample characteristics for both regular and occasional smokers, each stratified by age group. We conducted χ2-tests of independence and t-tests in order to investigate potential differences with regard to smoking status and age group. Second, we used multiple linear regression analysis in order to examine the determinants of the health warnings impact (WIS) and multiple logistic regression analysis in order to predict the intention to quit smoking using the WIS. Other predictor variables included the assessment of the validity of warnings, smoking risk assessment, the question whether or not neutral covers were used, the cigarette dependence score (FTCD), smoking status, and the additional variables.

In total, 5.08 % of all data used in this study were missing. The proportion of missing values across the variables varied between 0 % and 29 %. In order to handle missing data, we repeated regression analysis for each of the m=50 multiple imputed datasets and pooled the results according to Rubin’s rules [26]. In the imputation model, we used the entire set of predictor and outcome variables to impute the missing data. All statistical analyses were carried out using R version 3.4.2 [27], and we used the R-package mice version 2.30 for multiple imputation by chained equations [28].

Results

Sample characteristics and bivariate analysis

Within the total sample, 331 individuals smoked regularly, 129 individuals smoked occasionally, and 40 individuals had quit smoking in the last 12 months (ex-smokers). 50 % of participants were female, and age was between 16 and 89 years (M=37.5, SD=15.5). Sample characteristics for all smokers in total and for each group of regular and occasional smokers, stratified by age group, are listed in Table 1.

Table 1 Descriptive statistics for all smokers in total and for regular and occasional smokers, stratified by age group
Full size table

Smoking cessation because of pictorial CPHWs

None of the ex-smokers declared that the pictorial warnings on the cigarette packs were the main reason for smoking cessation. Only 4 persons (10.0 %) indicated that the pictures were among the reasons for quitting, and 36 persons (90.0 %) denied that the pictorial warnings had any effect on the decision to quit smoking.

Intention to quit smoking

27.2 % of the smokers denied any intention to quit smoking, while the remaining portion indicated at least a slight intention to quit. No significant difference for smoking status (χ2(1)=2.1, p=0.156) and age group (χ2(1)=2.1, p=0.146) was found.

Change in feelings because of the new CPHWs

84.3 % of the smokers reported no change in feelings because of the new packs, while a percentage of 15.7 % indicated that they now felt bad or very bad smoking. In this regard, occasional smokers (25.4 %) were found to be more likely to experience bad or very bad feelings than regular smokers (12.0 %; χ2(1)=11.4, p<0.001). Age had no effect (χ2(1)=0.76, p=0.385).

Foregoing cigarettes because of pictorial CPHWs

A vast majority of smokers (91.5 %) indicated that they had not reduced cigarette consumption due to the pictorial warnings, while the remaining portion reduced smoking at least a little. A higher proportion of occasional smokers (15.7 %), compared to regular smokers (5.8 %), and of the younger age group (14.9 %), compared to the older age group (6.8 %), reported to have reduced their cigarette consumption (χ2(1)=10.4, p=0.001 and χ2(1)=5.6, p=0.018, respectively).

Frequency of reading warnings

39.9 % of smokers had never read the warnings on the cigarette packs during the last weeks, while a percentage of 16.2 % had read the warnings once and 43.9 % had read the warnings more than once. No associations were found with regard to smoking status (χ2(1)=1.3, p=0.260) and age group (χ2(1)=0.4, p=0.525).

General attitude toward pictorial warnings

Overall, 34.0 % of smokers agreed when asked whether it is generally a good idea to show pictorial warnings on the cigarette packs as a deterrent, and this proportion was lower among regular (26.2 %) than among occasional smokers (55.7 %; χ2(1)=32.8, p<0.001), and lower among smokers aged 24 years or over (31.4 %) than among the younger age group (45.3 %; χ2(1)=32.8, p=0.017).

Assessment of the validity of warnings

The assessment with regard to the validity of the warnings did not statistically differ between regular and occasional smokers (t(446)=−1.9, p=0.063) or between the younger and the older age group (t(446)=−0.4, p=0.670).

Smoking risk assessment

Smoking status and age group also showed no effect on smoking risk assessment (t(425)=−0.9, p=0.363 and t(425)=0.4, p=0.669, respectively).

Use of neutral covers

A percentage of 18.3 % of smokers reported using neutral covers to hide the pictures on the cigarette packs, and regular smokers (22.0 %) were more likely to use neutral covers than occasional smokers (8.7 %; χ2(1)=9.8, p=0.002). No difference for age group was found (χ2(1)=0.6, p=0.447).

Determinants of the health warnings impact

Table 2 shows the pooled results of linear regression analysis regarding the impact of the health warnings (WIS). We found significant effects for validity assessment, for smoking risk assessment, cigarette dependence, and smoking status. An increasing endorsement of the validity of CPHWs and increasing levels of smoking risk assessment were related to higher values on WIS. The confidence intervals of the standardized coefficients also suggested that the effects of these two predictor variables did not differ considerably. Increasing cigarette dependence and regular (vs. occasional) smoking status, in turn, were related to lower levels on WIS.

Table 2 Linear regression analysis for the Warnings Impact Score (WIS)
Full size table

Predicting the intention to quit smoking

Table 3 shows the coefficients from the logistic regression analysis predicting the intention to quit smoking. We found two significant effects: higher values on WIS as well as increased smoking risk assessment were related to increased odds to report at least a slight intention to quit. The odds ratios also suggested a largely identical effect size for these two predictor variables.

Table 3 Logistic regression analysis for the intention to quit smoking
Full size table

Discussion

This paper constitutes the first study exploring and analysing smokers’ and ex-smokers’ responses to the newly implemented CPHWs in Austria. Although we found that the new packaging and labelling has a potential to persuade smokers to reduce or quit smoking, these warnings affected only a rather small group of smokers, while the vast majority appeared to remain rather unimpressed by this intervention. More specifically, 90 % of the ex-smokers denied any effect of the pictorial warnings on their decision to quit smoking and a similar proportion of smokers had not noticed any reduction in their cigarette consumption because of the pictures. These findings are comparable to a previous study that found slightly more than one tenth of European smokers to report cutting down on cigarettes due to health warnings, and this proportion was found to be higher in countries where pictorial warnings were already implemented (vs. countries with text-only warnings) [29].

The reasons for the rather weak impact of the warnings are diverse. One of the reasons concerns the fact that the general willingness to change smoking behaviour was quite weak in the sample. Arguably, it is much harder to convince poorly motivated individuals to stop or reduce smoking than highly motivated individuals (see e.g. [30]), particularly when using simple interventions that can be easily circumvented by consumers if they wish. In fact, more than half of the smokers had read the warnings on the cigarette packs at most once in the last weeks and a considerable proportion also indicated using neutral covers to hide the warnings on the packs. Such avoidance strategies likely prevent the warnings from taking effect. A longitudinal study has shown smokers who more strongly dealt with the warnings (reading, reflecting, discussing them) were more likely to have quit or reduced smoking three months later [31].

A further reason may reside in negative attitudes toward and beliefs about CPHWs in general. Only about one quarter of the regular smokers thought that the new cigarette packs were a reasonable intervention and a considerable portion of smokers even doubted the validity of the health warnings. The latter finding may be a result of smokers’ attempts to reduce cognitive conflict between the desire to continue smoking and its well-known detrimental health effects [32]. Doubting the validity of health-related information would be one of the strategies to eliminate or reduce such conflict. McMaster and Lee [33] showed that smokers (vs. non- and ex-smokers) estimated their own risk for developing lung cancer to be less than that of an “average smoker”, and smokers more often endorsed obviously untrue statements to justify smoking, even though there was no difference in factual knowledge about the risks of tobacco use between smokers and non- or ex-smokers.

In our study, we also found that the impact of the health warnings was less strong for smokers who doubted the validity of the warnings and the risks of smoking. Displaying the CPHWs – whether textual or pictorial – is probably not enough to overcome smokers’ denial and, eventually motivate them to consider a change in smoking behaviour [33]. Future studies should further examine the mechanisms that underlie the link between CPHWs and smoking behaviour, in order to identify ways of improving the efficacy of the health warnings. A recent meta-analysis of experimental studies demonstrated that there exists an array of psychosocial constructs potentially mediating the relationship between the warnings and changes in intentions and smoking behaviour [9]. Besides cognitive (e.g. denial of health risks), emotional (e.g. fear as a response to the warnings), and behavioural (e.g. avoiding the warnings) factors, the authors of the meta-analysis also recommended to analyse how social factors (e.g. social interactions with peers) influence effectiveness of the warnings.

Strengths and limitations

The present study explores smokers’ and ex-smokers’ responses to the CPHWs newly implemented in Austria in 2016. This research thus deals with a topical public health issue and our findings might be of interest for public health policies aiming to reduce the global burden of tobacco use. The comprehensive questionnaire used in this survey study allowed us to provide information on different facets of smoking-related issues (e.g. cognitive, affective, and behavioural responses to the CPHWs) on the one hand and to reveal potential factors that may limit the level of impact of the CPHWs on the other hand. Finally, the scales used in this study showed satisfactory psychometric properties in terms of internal consistency and dimensionality.

One shortcoming of the current study resides in the cross-sectional nature of the survey design. The revealed relationships are only correlational and do not permit inferences about cause and effect. A second limitation concerns the self-report character of the analysed data. It is possible that the health warnings also operate on a subconscious or implicit level (see e.g. [34]) and that smokers/ex-smokers may thereby fail to explicitly notice potential effects of the warnings. And thirdly, the relatively small sample sizes in some of the subgroups (i.e. the ex-smokers) compromises generalizability of the findings for these subgroups.

Conclusions

In conclusion, although we found that the CPHWs might have a potential to promote a change in smoking behaviour, the impact of the warnings seemed to be less strong among “heavy” smokers and among smokers who questioned the detrimental effects smoking can have on their health. The main challenges for public health policies will thus be to increase the salience of health warnings in order to enhance the cognitive processing of smoking-related information and to overcome smokers’ denial of the well-publicised ill-effects of tobacco use [9, 31, 35].

Abbreviations

CPHWs:

Cigarette pack health warnings

FCTC:

Framework convention on tobacco control

FTCD:

Fagerström test for cigarette dependence

IFES:

The Institute for empirical social studies

WHO:

World Health Organisation

WIS:

Warnings impact score

References

  1. World Health Organisation. Who report on the global tobacco epidemic, 2017: Monitoring tobacco use and prevention policies. Geneva: World Health Organization; 2017. http://apps.who.int/iris/bitstream/10665/255874/1/9789241512824-eng.pdf. Accessed 26 July 2017.

  2. World Health Organisation. WHO global report: Mortality Attributable to Tobacco. Geneva: World Health Organization; 2012. http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf. Accessed 26 July 2017.

  3. World Health Organisation. WHO framework convention on tobacco control. Geneva: World Health Organization; 2005. http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf. Accessed 25 July 2017.

  4. Levy DT, Mays D, Yuan Z, Hammond D, Thrasher JF. Public health benefits from pictorial health warnings on US cigarette packs: A SimSmoke simulation. Tob Control. 2017; 26:649–55.

    Article  PubMed  Google Scholar 

  5. European Parliament and Council of the European Union. Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014, on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products and repealing Directive 2001/37/EC. Off J Eur Union. 2014; 57:1–38.

    Google Scholar 

  6. BGBl I No 22. Bundesgesetz über das Herstellen und Inverkehrbringen von Tabakerzeugnissen und verwandten Erzeugnissen sowie die Werbung für Tabakerzeugnisse und verwandte Erzeugnisse und den Nichtraucherinnen- bzw. Nichtraucherschutz. Austria: Austrian Federal Chancellery; 2016. https://www.ris.bka.gv.at/eli/bgbl/I/2016/22/20160520. Accessed 3 Oct 2017.

  7. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong HH, et al. Impact of graphic and text warnings on cigarette packs: Findings from four countries over five years. Tob Control. 2009; 18(5):358–64.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach LE, et al. Effect of pictorial cigarette pack warnings on changes in smoking behavior: A randomized clinical trial. JAMA Intern Med. 2016; 176(7):905–12.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control. 2016; 25(3):341–54.

    Article  PubMed  Google Scholar 

  10. Thrasher JF, Hammond D, Fong GT, Arillo-Santillán E. Smokers’ reactions to cigarette package warnings with graphic imagery and with only text: A comparison between Mexico and Canada. Salud Publica Mex. 2007; 49(Suppl 2):233–40.

    Article  Google Scholar 

  11. Hammond D, Fong GT, McDonald PW, Brow KS, Cameron R. Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. Am J Public Health. 2004; 94(8):1442–5.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Vardavas CI, Connolly G, Karamanolis K, Kafatos A. Adolescents perceived effectiveness of the proposed European graphic tobacco warning labels. Eur J Public Health. 2009; 19(2):212–7.

    Article  PubMed  Google Scholar 

  13. Azagba S, Sharaf MF. The effect of graphic cigarette warning labels on smoking behavior: Evidence from the Canadian experience. Nicotine Tob Res. 2013; 15(3):708–17.

    Article  PubMed  Google Scholar 

  14. Parada H, Hall MG, Boynton MH, Brewer NT. Trajectories of responses to pictorial cigarette pack warnings. Nicotine Tob Res. 2017;:ntx182.

  15. Choi SH, Stommel M. Impact of age at smoking initiation on smoking-related morbidity and all-cause mortality. Am J Prev Med. 2017; 53(1):33–41.

    Article  PubMed  Google Scholar 

  16. Azagba S, Baskerville NB, Minaker L. A comparison of adolescent smoking initiation measures on predicting future smoking behavior. Prev Med Rep. 2015; 2:174–7.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Reidpath DD, Davey TM, Kadirvelu A, Soyiri IN, Allotey P. Does one cigarette make an adolescent smoker, and is it influenced by age and age of smoking initiation? Evidence of association from the U.S. Youth risk behavior surveillance system. Prev Med. 2014; 59:37–41.

    Article  PubMed  Google Scholar 

  18. Moodie C, MacKintosh AM, Hammond D. Adolescents’ response to text-only tobacco health warnings: Results from the 2008 UK Youth Tobacco Policy Survey. Eur J Public Health. 2010; 20(4):463–9.

    Article  PubMed  Google Scholar 

  19. Moodie C, Mackintosh AM, Hastings G. Adolescents’ response to pictorial warnings on the reverse panel of cigarette packs: A repeat cross-sectional study. Tob Control. 2015; 24(e1):e93–7.

    Article  PubMed  Google Scholar 

  20. Hitchman SC, Mons U, Nagelhout GE, Guignard R, Mcneill A, Willemsen MC, et al. Effectiveness of the European Union text-only cigarette health warnings: Findings from four countries. Eur J Public Health. 2012; 22(5):693–9.

    Article  PubMed  Google Scholar 

  21. Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: Findings from the international tobacco control four country study. Am J Prev Med. 2007; 32(3):202–9.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Fagerström K. Determinants of tobacco use and renaming the FTND to the Fagerstrom̈ test for cigarette dependence. Nicotine Tob Res. 2012; 14(1):75–8.

    Article  PubMed  Google Scholar 

  23. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerstrom̈ test for nicotine dependence: A revision of the Fagerstrom̈ tolerance questionnaire. Br J Addict. 1991; 86(9):1119–27.

    CAS  Article  PubMed  Google Scholar 

  24. Hammond D. Health warning messages on tobacco products: A review. Tob Control. 2011; 20(5):327–37.

    Article  PubMed  Google Scholar 

  25. Hammond D, Reid JL, Driezen P, Boudreau C. Pictorial health warnings on cigarette packs in the United States: an experimental evaluation of the proposed FDA warnings. Nicotine Tob Res. 2013; 15(1):93–102.

    Article  PubMed  Google Scholar 

  26. Rubin DB. Multiple imputation for nonresponse in surveys. New York: Wiley; 1987.

    Book  Google Scholar 

  27. R Core Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2017. http://www.R-project.org/.

    Google Scholar 

  28. Buuren SV, Groothuis-Oudshoorn K. mice: Multivariate imputation by chained equations in R. J Stat Softw. 2011; 45(3):1–67.

    Article  Google Scholar 

  29. Agaku IT, Filippidis FT, Vardavas CI. Effectiveness of text versus pictorial health warning labels and predictors of support for plain packaging of tobacco products within the European Union. Eur Addict Res. 2015; 21(1):47–52.

    Article  PubMed  Google Scholar 

  30. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol. 1983; 51(3):390–5.

    CAS  Article  PubMed  Google Scholar 

  31. Hammond D, Fong GT, McDonald PW, Cameron R, Brown KS. Impact of the graphic Canadian warning labels on adult smoking behaviour. Tob Control. 2003; 12(4):391–5.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  32. Festinger L. A Theory of Cognitive Dissonance. California: Stanford University Press; 1957.

    Google Scholar 

  33. McMaster C, Lee C. Cognitive dissonance in tobacco smokers. Addict Behav. 1991; 16(5):349–53.

    CAS  Article  PubMed  Google Scholar 

  34. Volchan E, David IA, Tavares G, Nascimento BM, Oliveira JM, Gleiser S, et al. Implicit motivational impact of pictorial health warning on cigarette packs. PLOS ONE. 2013; 8(8):e72117.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  35. Yong HH, Borland R, Thrasher JF, Thompson ME, Nagelhout GE, Fong GT, et al. Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychol. 2014; 33(11):1410–20.

    Article  PubMed  PubMed Central  Google Scholar 

  36. McFadden D. Conditional logit analysis of qualitative choice behavior In: Zarembka P, editor. Frontiers of Econometrics. New York: Academic Press: 1973. p. 105–42.

    Google Scholar 

  37. Cox DR, Snell EJ. Analysis of Binary Data. 2nd ed. London: Chapman & Hall; 1989.

    Google Scholar 

  38. Nagelkerke NJD. A note on a general definition of the coefficient of determination. Biometrika. 1991; 78(3):691–2.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Author information

Authors and Affiliations

  1. Institute of Social Medicine and Epidemiology, Medical University of Graz, Universitaetsstrasse 6/I, Graz, 8010, Austria

    Hannes Mayerl, Erwin Stolz & Wolfgang Freidl

Authors
  1. Hannes Mayerl
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Erwin Stolz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wolfgang Freidl
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

HM, ES and WF conceived and designed the study, analysed the data and interpreted the study results. HM wrote the paper. ES and WF critically reviewed drafts of the paper. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Wolfgang Freidl.

Ethics declarations

Ethics approval and consent to participate

Informed consent was obtained from all individual participants included in the study. The Ethics Committee of the Medical University of Graz approved the conductance of this study (EK-Number: 29-373 ex 16/17).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Mayerl, H., Stolz, E. & Freidl, W. Responses to textual and pictorial cigarette pack health warnings: findings from an exploratory cross-sectional survey study in Austria. BMC Public Health 18, 442 (2018). https://doi.org/10.1186/s12889-018-5342-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-018-5342-8

Keywords

  • smoking
  • cigarette packs
  • health warnings
  • packaging and labelling

BMC Public Health

ISSN: 1471-2458

Contact us