You are here

  • Home
  • Archive
  • Volume 15, Issue 1
  • Impact of warning pictorials and size on perceived effectiveness of cigar warning labels in a nationally representative between-subjects experiment

Article Text

Article menu

Download PDFPDF

Smoking and tobacco
Original research
Impact of warning pictorials and size on perceived effectiveness of cigar warning labels in a nationally representative between-subjects experiment
  1. Adam O Goldstein1,2,
  2. Michelle Z Yang3,
  3. Kristen L Jarman1,
  4. Tara L Queen4,
  5. Sonia A Clark1,
  6. Leah M Ranney1,2,
  7. Jennifer Cornacchione Ross5,
  8. Paschal Sheeran2,3,
  9. Chineme Enyioha1,2,
  10. James F Thrasher6,
  11. Desmond Jenson7,
  12. Sarah D Kowitt1,2
  1. 1 Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2 Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3 Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  4. 4 Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  5. 5 Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
  6. 6 Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
  7. 7 Public Health Law Center, Mitchell Hamline School of Law, Saint Paul, Minnesota, USA
  1. Correspondence to Dr Adam O Goldstein; adam_goldstein{at}med.unc.edu

Abstract

Background People who smoke cigars often have misperceptions about the associated risks, contributing to rises in smoking rates. This study investigates the perceived warning effectiveness (PWE) of health warning labels (HWLs) on cigar packages. We tested the impact of warning type and warning size in the HWLs on PWE and other health outcomes.

Data and methods In a between-subjects experimental design, participants (n=809) who used little cigars or cigarillos in the past 30 days were randomly assigned to one of four conditions: text-only at 30% size, pictorial+text warning at 30% size, text-only at 50% size and pictorial+text warning at 50% size. In each condition, participants rated six cigarillo HWLs on PWE, self-reported learning, thinking about risks, new knowledge, perceived enjoyment and negative affect. Reactance to the labels was also measured. Data were analysed with mixed-effects models.

Results Pictorial+text cigarillo HWLs were deemed more effective than text-only HWLs in PWE (b=0.34, SE=0.08, p<0.001), self-reported learning (b=0.20, SE=0.08, p=0.01), thinking about risks (b=0.18, SE=0.08, p=0.03) and new knowledge (b=0.34, SE=0.12, p<0.01). They also elicited more negative affect than text-only warnings (b=0.39, SE=0.08, p<0.001). Warning size did not impact outcomes, and neither warning type nor size predicted perceived enjoyment of smoking cigarillos or reactance to the warnings.

Conclusion Including images with text warning statements for cigarillos can increase PWE. Our findings provide important insights for the US Food and Drug Administration and international regulatory agencies in designing new HWLs for cigars that can more effectively communicate smoking risks, address misinformation and potentially reduce cigar smoking.

  • Smoking Reduction
  • PUBLIC HEALTH
  • Psychosocial Intervention

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2024-088482

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • Test of the perceived warning effectiveness of a brand-new proposed set of cigar health warning labels that manipulate both content type and warning size.

    • Recruited a representative and diverse sample of people who smoke little cigars and cigarillos to participate in the study.

    • Self-reports of perceived warning effectiveness, new learning, negative effect and thinking about risks.

    Introduction

    Significant rises in rates of cigar smoking occurred over the last 20 years, with consumption increasing despite a large decrease in cigarette smoking.1 This is concerning as cigar smoking accounts for approximately 9000 premature deaths and over 140 000 years of potential life lost annually in US adults.2 Little cigars and cigarillos (LCCs) are the most commonly used cigars, accounting for 97.3% of unit sales in the US cigar market.3 The use of LCCs is prominent among males, young adults and low socioeconomic populations, a trend attributable to factors like affordability, a wide range of flavour options, targeted advertisement in disadvantaged neighbourhoods and fewer regulations compared with cigarettes.4–7

    Despite evidence that cigar smoking poses similar health risks as cigarette smoking (eg, lung cancer, oral cancer, heart cancer), people who smoke LCCs often misunderstand these risks.8 9 Young adults tend to underestimate the harmfulness of smoking cigars, believing that it is less risky than smoking cigarettes.10–14 Some young adults believe that, so long as the use of LCCs is infrequent, smoking LCCs is unlikely to lead to negative health effects.15 Since beliefs about risks influence smoking intentions, the prevalence of misperceptions surrounding LCC health risks is alarming.16 Misperceptions about cigar health risks may be contributing to the rising rates of cigar consumption.

    Effective health messaging is important for communicating the dangers associated with smoking LCCs and correcting misperceptions. In light of this public health concern, the US Food and Drug Administration (FDA) proposed six rotating, text-only warnings for cigar packaging and advertising in May 2016. However, a US Federal District Court vacated the health warning requirements for cigars in 2020, ruling that the FDA failed to provide justifiable evidence for requiring such warnings. While research for cigarette warning labels suggests that effective labels should have multiple rotating sets, contain graphic images of associated health risks and be large,17–21 less research exists for cigar products. As such, the court posited that warnings shown to be effective for one tobacco product (ie, cigarettes) cannot be extrapolated to other tobacco products (ie, cigars).

    Some studies have sought to understand how characteristics of LCC health warning labels (HWLs) influence the knowledge, attitudes and beliefs of people who smoke LCCs. For instance, the inclusion of warning labels on cigarillo packaging reduces favourable perceptions of product taste and smell.22 Young adults show a preference for graphic images and believe such images would help promote an understanding of product risk.23 24 Additionally, they feel more negative emotion in reaction to pictorial cigarillo warnings and perceive those warnings to be more effective than text-only warnings.25 One way researchers examine the effectiveness of specific health consequence warnings is by measuring perceived warning effectiveness (PWE), which indicates the potential for a warning to change health behaviour.26 PWE measures have been consistently shown to predict the actual effectiveness of messages and warnings in influencing behaviour.27 28 Cigar warning label themes pertaining to health consequences for the cardiovascular system, mouth and digestive system were perceived to be more effective than warnings about risks to the reproductive system or about secondhand smoke.29 30 These studies contributed important initial insights into the effects of pictorial warnings and different health warning themes.

    Few studies to date have examined how cigar warning size and warning type impact PWE. While cigarette research supports the effectiveness of larger, graphic, pictorial warnings, it is possible that health warnings that are effective for cigarettes may not be equally effective for cigars, due to differences in consumer demographics (eg, higher proportion of cigar use in young adults, Hispanic populations and non-Hispanic black or African American populations), product characteristics (eg, cigars are more affordable and include non-menthol flavour options) and usage trends (eg, cigars are used on fewer days per month).4–6 15 31 The present study aims to address this gap by identifying HWL characteristics that are most effective for communicating cigar health risks. Specifically, we offer an empirical test of the impact of warning type (eg, pictorial+text vs text-only) and warning size (30% of the pack vs 50% of the pack) on cigarillo HWLs.

    Methods

    Participants

    We recruited participants from NORC’s AmeriSpeak Panel. Funded and operated by NORC at the University of Chicago, AmeriSpeak is a probability-based panel designed to be representative of the US household population. Eligible participants were US adults at least 18 years of age who reported smoking cigarillos or little cigars in the last 30 days. Participants were sampled using a total of 48 sample strata based on age, race/Hispanic ethnicity, education and gender. Data collection took place between 3 March 2022 and 18 March 2022, and the survey took participants approximately 15 min to complete. In total, six cases were removed from the sample due to speeding (ie, those who completed the survey in less than one-third the mediation duration) or high refusal rates (ie, those who skipped or refused more than 50% of the eligible questions). The study was pre-registered at AsPredicted (#88507).

    Patient and Public Involvement

    Members of the public were not involved in the design, conduct, reporting or dissemination plans of our research.

    Design and procedures

    We conducted a 2 (warning size: 30% vs 50%) × 2 (warning type: text-only vs pictorial+text) between-subjects experiment. Participants were presented with digital images of different HWLs on the cigarillo packaging of ‘Brentfield’, a fictitious cigar brand,22 32 via a survey programmed in Qualtrics. These new HWLs were designed by the research team. Brentfield was chosen because, as a fake brand, it minimises the influence of pre-existing brand perceptions on participant responses.33 34 We chose to depict cigarillos because cigarillos have the highest rate of use among cigar products.35 At the start of the study, participants answered screening questions about whether they had ever used cigarillos, and if so, how many days they had smoked a cigarillo in the past 30 days. They were then asked the same questions for little cigars. To be eligible for the study, participants had to have used a cigarillo or little cigar for at least 1 day in the past 30 days. Eligible participants were randomly assigned to one of four conditions: (1) pictorial+text at 50% package size, (2) pictorial+text at 30% package size, (3) text-only at 50% package size and (4) text-only at 30% package size. Within their condition, participants were presented with six cigarillo package warnings in a random order. These warnings contained statements about different health effects associated with smoking cigars: bladder cancer and blood in urine, lung cancer and lung disease, colon cancer, pharyngeal and throat cancer, oesophageal cancer, and stroke and blood clots (see figure 1). The statements used in the warning text were previously developed by our study team from a series of studies29 30 to identify a comprehensive set of effective cigarillo warning statements and images.

    Figure 1
    Figure 1

    Example stimuli for experimental conditions. Left to right: (1) pictorial+text at 30% package size, (2) text-only at 30% package size, (3) pictorial+text at 50% package size, (4) text-only at 50% package size. ‘Brentfield’ is a fictitious cigar brand.

    Measures

    After viewing each cigarillo package with their assigned warning label, participants answered survey items to assess PWE using a three-item scale (eg, ‘How much does the warning make you concerned about the health effects of smoking cigars?’; 1=not at all to 5=a great deal),30 self-reported learning (ie, ‘How much does this warning give you a better understanding of the consequences of cigar smoking?’; 1=not at all to 5=a great deal), thinking about risks (ie, ‘How much does this warning make you think about the health risks of cigar smoking?’; 1=not at all to 5=a great deal), new knowledge (ie, ‘Before today, had you heard that cigar smoking causes [health complication from warning]?’; 0=no, 1=yes), perceived enjoyment (eg, ‘How enjoyable would it be to smoke these cigars?’; 1=not at all to 5=extremely) and negative affect using a three-item scale (eg, ‘How much does this cigar warning make you feel scared about cigar smoking?’; 1=not at all to 5=a great deal). After viewing all six warning labels, participants also reported their reactance to the labels on a three-item scale (eg, ‘These warnings are trying to manipulate me’; 1=strongly disagree to 5=strongly agree).36 We also surveyed participant demographics: age in years, sex (ie, female, male), race/ethnicity (ie, white, non-Hispanic; black/African American, non-Hispanic; other or multi-race, non-Hispanic; Hispanic) and education (ie, less than high school diploma, GED/high school diploma, some college/Associate’s degree, Bachelor’s degree or higher).

    Analysis

    We conducted unweighted linear mixed-effects models using REML (ie, restricted maximum likelihood) estimation to examine the impact of warning type and warning size on our outcomes (ie, PWE, self-reported learning, thinking about risks, perceived enjoyment, negative affect). Warning type and size were entered as fixed effects while participants were entered as a random effect; the models did not control for demographic factors. The interactions between warning type and size were not significant, and thus, we only looked at main effects. We also fitted a mixed-effects logistic regression using the GLIMMIX (eg, generalised linear mixed models) procedure to predict new knowledge from warning type and size. Again, the interaction between the manipulations was not significant and consequently excluded from the model. The impact of warning type and size on reactance was evaluated through fitting a linear regression model. All analyses were conducted using SAS V.9.4 with α=0.05.

    Results

    Participant characteristics

    A final sample size of 809 participants (52.8% female) completed the study. Overall sample demographics are reported in table 1 below. The age distribution was similar for those aged 18–34, 35–54 and greater than age 55 years. About 52.7% identified as white, 19.2% as black, 17.2% as Hispanic and 11.0% as other racial categories. Approximately 94.6% of participants reported that they had ever used cigarillos, while 66.3% of reported that they had ever used little cigars. Randomisation of participants into the four conditions was successful, resulting in groups that were comparable across age, gender, race and ethnicity, and educational attainment.

    View this table:
    Table 1

    Sample demographics

    Multilevel analyses of repeated measures

    The mixed-effects model revealed a significant main effect of warning type. Inclusion of pictorial+text in warnings was associated with higher ratings of PWE (b=0.34, SE=0.08, p<0.001), self-reported learning (b=0.20, SE=0.08, p=0.01), thinking about risks (b=0.18, SE=0.08, p=0.03) and negative affect (b=0.39, SE=0.08, p<0.001). Additionally, the mixed-effects logistic model showed that warning type significantly predicted whether participants reported having gained new knowledge (b=0.34, SE=0.12, p<0.01). Specifically, participants who saw pictorial+text warnings were more likely to say that they already knew about the health impacts of smoking cigarillos than those who saw the text-only warnings (OR=1.40, 95% CI (1.11, 1.77)). Warning type did not significantly predict perceived enjoyment (b=−0.11, SE=0.07, p=0.09). Warning size was not a significant predictor of PWE (b=−0.06, SE=0.08, p=0.41), self-reported learning (b=−0.05, SE=0.08, p=0.54), thinking about risks (b=−0.03, SE=0.08, p=0.76), negative affect (b=−0.11, SE=0.08, p=0.19), new knowledge (b=0.04, SE=0.12, p=0.75) nor perceived enjoyment (b=0.05, SE=0.07, p=0.49). Model outcomes are reported in table 2, and descriptive statistics by condition are reported in online supplemental table 1.

    Supplemental material

    View this table:
    Table 2

    Mixed-effects models of experimental manipulations on outcomes

    Regression analysis of reactance

    Results of the regression model indicated that there was no significant main effect of warning type on reactance (b=0.13, SE=0.07, p=0.06). Warning size also did not significantly predict reactance (b=0.12, SE=0.07, p=0.11).

    Discussion

    Our study reports the perceived effectiveness of different cigarillo HWL characteristics among people who report having ever smoked LCCs. Cigarillo warnings that combined pictorials and text—compared with text only—significantly increased perceived warning effectiveness, self-reported learning, thinking about risks and negative affect. Moreover, pictorial+text versus text-only warnings did not differentially affect people’s perceived enjoyment of smoking cigarillos or their reactance to warning messages. Warning size was not a significant predictor of any measured outcomes.

    That pictorial+text warning labels on cigarillo packages increase PWE is noteworthy. Previous research on cigarette warning labels demonstrated that increased PWE for pictorial (vs text-only) warnings was associated with higher quit intentions.37 Accordingly, our findings suggest that pictorial cigar warnings could increase quit intentions, a hypothesis to be tested in future research. These findings also align with extant neighbouring literature on the effectiveness of pictorial warnings for cigarette packages (ie, people who smoke cigarettes report cigarette HWLs with pictorial warnings as more effective than text-only warnings38) and are consistent with findings that pictorial warnings on cigarillo packages are perceived by young adults to be more effective than text-only warnings.25 39

    One plausible explanation for the finding that pictorial cigarillos warnings increased PWE is through the elicitation of negative emotional responses. People tend to exhibit a negativity bias, whereby they are more likely to pay attention to and learn from information that evokes negative emotions.40 Furthermore, studies on cigarette warning labels have shown that pictorial warnings capture people’s attention more than text-only warnings.41 Importantly, not only do people more readily look at pictorial warnings, but they also spend more time looking at such warnings and recall information more accurately.42 Our study extends this line of research to cigar warning labels. In our study, the pictorial+text cigarillo warning labels depicted negative consequences of smoking cigars, and participants reported that these warnings elicited stronger negative emotions. By evoking negative emotions and making health consequences salient, pictorial warnings could have facilitated the internalisation of the risks of cigar smoking. A second way pictorial warnings can increase PWE is through increased ease of processing. Visual elements aid the understanding of information that is conveyed through text.43 This is particularly important when conveying health risks associated with smoking cigars. While terms like ‘pharyngeal cancer’ might feel abstract or challenging to understand for the average person, images illustrating damaged body parts can effectively convey these health consequences. The combination of pictorial and textual elements likely provides a more comprehensive approach to communicating risks.

    Interestingly, participants in the pictorial+text condition reported higher PWE and greater understanding of the consequences of cigar smoking despite reporting that they already knew more about the negative health consequences of smoking cigars. Two possible explanations exist for this finding. First, there has been a rise in the social unacceptability of smoking in the USA, and increased presence of tobacco control campaigns on social media platforms.44 45 This could have driven a social desirability bias in participants to present themselves as more knowledgeable about the health consequences of smoking cigarillos than they actually possess. Second, research shows that people who smoke know and acknowledge the consequences of smoking but underestimate their personal risk for health complications.46 47 We suspect that although participants in the pictorial+text warning condition report already knowing about health complications, the combination of pictorial and text nevertheless helped participants to reflect on their personal risks, driving an increase in thinking about risks, self-reported learning and PWE.

    We did not find a significant effect of cigarillo warning size on outcomes. This is consistent with some research showing that increasing pictorial HWLs above 30% of the package size does not reduce ratings of positive pack characteristics for plain (vs branded) cigarette packs.48 However, it is possible that the range of warning sizes we manipulated was not wide enough to detect an effect. Differences in physiological response (ie, startle reflex) to warning labels can be detected when comparing labels that were 30% of the pack versus 60% of the pack.49 Therefore, the difference between a warning size of 30% versus 50% may not be substantial enough to produce noticeable effects in a study of this type. Another explanation may be that size effects are more likely to be observed with long-term exposures on a physical package than with short-term exposure on a digital screen.

    The present findings have several practical implications. First, our results suggest that effective LCC HWLs should include pictorials alongside text. Similar to cigarette users’ reactions to HWLs, we find that HWLs with pictorial and text are perceived to be more effective than text-only warnings. LCC pictorials depicting external and internal harm to the body are perceived to be more effective than internal harm depictions alone.50 People who smoke LCCs also believe that graphic pictorials are more effective than abstract pictorials.25 Studies have shown that people who smoke cigarettes perceive HWLs that take up 50% of the packs to be effective,21 and the FDA finalised a set of 11 cigarette HWLs in 2020 that complied with Congressional legislation mandating that pictorial cigarette warnings occupy 50% of cigarette packages. While our findings did not show a difference in PWE by warning size, more research will need to be done to assess whether 30% is truly large enough for cigar warnings. A final point to consider is the demographic characteristics of any subjects depicted in HWLs. LCC use is especially high among young adults, Hispanics and non-Hispanic black Americans.4 Despite WHO recommendations to tailor tobacco warnings to the consumer base, the majority of existing tobacco warnings depict white males.51 Further research can help determine if cigar HWL effectiveness improves when the label’s subject demographic reflects the demographic of people who smoke cigars.

    Some limitations exist. While we relied on self-report measures to assess the perceived effectiveness of warning labels, the predictive validity of PWE for behaviour change has been established.26 27 However, future studies could obtain behavioural measures to directly evaluate how warning label characteristics impact smoking cessation. Additionally, the limited variations of warning sizes may have impacted our ability to detect a significant effect of warning sizes larger than 30% on outcomes. Future studies can explore whether message effectiveness varies when comparing larger differences in warning size (eg, 30% of the pack vs 75% of the pack). Furthermore, our research tested HWLs for a fictitious brand to control for brand biases; additional research is necessary to investigate whether these findings are generalisable to existing LCC brands. Our research examined warnings that impact LCC use, and research on the impact of similar warnings on large and premium cigars is needed. A final limitation concerns any potential confounding, and while it is impossible to account for all confounders, study design techniques such as randomisation significantly reduce confounding.52 53 By incorporating randomisation in both the condition assignment and order of label presentation, the observed results are more readily attributed to the experimental manipulation rather than confounding factors.

    Our study possesses several strengths. First, we offered a first test of the PWE of a brand-new proposed set of LCC HWLs that manipulate both content type and warning size. Second, our study draws from a representative and diverse sample of people who smoke LCCs, enhancing the generalisability of our findings to suggest that our pictorial+text warning statements would indeed be perceived as effective for the target population. These findings also have important policy implications. With the recent court decision to vacate the requirement of health warnings for cigar products, manufacturers can optionally display existing text warnings on cigar products. Research indicates that widespread misinformation about the negative health consequences of cigars already exists.8–15 The lack of effective LCC health warning requirements could exacerbate the prevalence of misinformation and compromise the health of people who smoke LCCs. It is imperative to design and implement LCC HWLs that aid people’s comprehension of risks. Our study found that people who smoke LCCs not only perceived our pictorial+text warnings to be more effective than text-only warnings, but they also reported thinking more about risks than with text-only warnings.

    Conclusions

    Our study shows that including pictorials alongside text warnings could be an effective way to communicate risks of cigar smoking and ultimately reduce rates of cigar smoking-related health complications in the USA. These findings provide important insights for policy-makers in USA and internationally charged with implementing new cigar warnings.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by University of North Carolina at Chapel Hill IRB (Approval number: 21-2454). Participants gave informed consent to participate in the study before taking part.

    References

    1. ↵
      2. Wang TW ,
      3. Kenemer B ,
      4. Tynan MA , et al
      . Consumption of Combustible and Smokeless Tobacco - United States, 2000-2015. MMWR Morb Mortal Wkly Rep 2016;65:1357–63. doi:10.15585/mmwr.mm6548a1
      OpenUrlPubMed
    2. ↵
      2. Nonnemaker J ,
      3. Rostron B ,
      4. Hall P , et al
      . Mortality and economic costs from regular cigar use in the United States, 2010. Am J Public Health 2014;104:e86–91. doi:10.2105/AJPH.2014.301991
      OpenUrlCrossRefPubMed
    3. ↵
      2. Wang X ,
      3. Kim Y ,
      4. Borowiecki M , et al
      . Trends in Cigar Sales and Prices, by Product and Flavor Type-the United States, 2016-2020. Nicotine Tob Res 2022;24:606–11. doi:10.1093/ntr/ntab238
      OpenUrlCrossRefPubMed
    4. ↵
      2. Chen-Sankey JC ,
      3. Mead-Morse EL ,
      4. Le D , et al
      . Cigar-Smoking Patterns by Race/Ethnicity and Cigar Type: A Nationally Representative Survey Among U.S. Adults. Am J Prev Med 2021;60:87–94. doi:10.1016/j.amepre.2020.07.005
      OpenUrlPubMed
    5. ↵
      1. U.S. Department of Health and Human Services
      . Preventing tobacco use among youth and young adults: a report of the surgeon general. Atlanta U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health; 2012. Available: https://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm
    6. ↵
      2. Kong AY ,
      3. Queen TL ,
      4. Golden SD , et al
      . Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015. Nicotine Tob Res 2020;22:2170–7. doi:10.1093/ntr/ntaa005
      OpenUrlPubMed
    7. ↵
      2. Sun R ,
      3. Chana SM ,
      4. Hawes E , et al
      . Examining Racial/Ethnic and Income Disparities on Tobacco Product Use Among US Adults Within Wave 5 of the PATH Study. J Addict Med 2023;17:373–8. doi:10.1097/ADM.0000000000001124
      OpenUrlPubMed
    8. ↵
      2. Baker F
      . Health Risks Associated With Cigar Smoking. JAMA 2000;284:735. doi:10.1001/jama.284.6.735
      OpenUrlCrossRefPubMedWeb of Science
    9. ↵
      2. Chang CM ,
      3. Corey CG ,
      4. Rostron BL , et al
      . Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health 2015;15:390. doi:10.1186/s12889-015-1617-5
    10. ↵
      2. Wackowski OA ,
      3. Delnevo CD
      . Young Adults’ Risk Perceptions of Various Tobacco Products Relative to Cigarettes: Results From the National Young Adult Health Survey. Health Educ Behav 2016;43:328–36. doi:10.1177/1090198115599988
      OpenUrlCrossRefPubMed
    11. ↵
      1. Monitoring the Future
      . Trends in harmfulness of drugs as perceived by 8th graders. 2019. Available: http://monitoringthefuture.org/data/19data/19drtbl9.pdf
    12. ↵
      1. Monitoring the Future
      . Trends in harmfulness of drugs as perceived by 10th graders. 2019. Available: http://monitoringthefuture.org/data/19data/19drtbl10.pdf
    13. ↵
      1. Monitoring the Future
      . Trends in harmfulness of drugs as perceived by 12th graders. 2019. Available: http://monitoringthefuture.org/data/19data/19drtbl11.pdf
    14. ↵
      2. Smith SY ,
      3. Curbow B ,
      4. Stillman FA
      . Harm perception of nicotine products in college freshmen. Nicotine Tob Res 2007;9:977–82. doi:10.1080/14622200701540796
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      2. Cornacchione J ,
      3. Wagoner KG ,
      4. Wiseman KD , et al
      . Adolescent and Young Adult Perceptions of Hookah and Little Cigars/Cigarillos: Implications for Risk Messages. J Health Commun 2016;21:818–25. doi:10.1080/10810730.2016.1177141
      OpenUrlCrossRefPubMed
    16. ↵
      2. Sterling KL ,
      3. Majeed BA ,
      4. Nyman A , et al
      . Risk Perceptions of Little Cigar and Cigarillo Smoking Among Adult Current Cigarette Smokers. Nicotine Tob Res 2017;19:1351–8. doi:10.1093/ntr/ntw244
      OpenUrlPubMed
    17. ↵
      2. Haines-Saah RJ ,
      3. Bell K ,
      4. Dennis S
      . A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom, and the United States. Am J Public Health 2015;105:e61–9. doi:10.2105/AJPH.2014.302362
      OpenUrlCrossRefPubMed
    18. ↵
      2. Hammond D ,
      3. Fong GT ,
      4. Borland R , et al
      . Communicating Risk to Smokers: The Impact of Health Warnings on Cigarette Packages. Am J Prev Med 2007;32:202–9. doi:10.1016/j.amepre.2006.11.011
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      2. Nan X ,
      3. Zhao X ,
      4. Yang B , et al
      . Effectiveness of cigarette warning labels: examining the impact of graphics, message framing, and temporal framing. Health Commun 2015;30:81–9. doi:10.1080/10410236.2013.841531
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      2. Kees J ,
      3. Burton S ,
      4. Andrews JC , et al
      . Tests of Graphic Visuals and Cigarette Package Warning Combinations: Implications for the Framework Convention on Tobacco Control. J Public Policy & Marketing 2006;25:212–23. doi:10.1509/jppm.25.2.212
      OpenUrlCrossRef
    21. ↵
      2. Hammond D ,
      3. Reid JL ,
      4. Driezen P , et al
      . Pictorial health warnings on cigarette packs in the United States: an experimental evaluation of the proposed FDA warnings. Nicotine Tob Res 2013;15:93–102. doi:10.1093/ntr/nts094
      OpenUrlCrossRefPubMedWeb of Science
    22. ↵
      2. Meernik C ,
      3. Ranney LM ,
      4. Lazard AJ , et al
      . The effect of cigarillo packaging elements on young adult perceptions of product flavor, taste, smell, and appeal. PLoS One 2018;13:e0196236. doi:10.1371/journal.pone.0196236
    23. ↵
      2. Gratale SK ,
      3. Jeong M ,
      4. Sidhu A , et al
      . Young adults’ cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study. BMJ Open 2022;12:e061064. doi:10.1136/bmjopen-2022-061064
    24. ↵
      2. Cornacchione Ross J ,
      3. King JL ,
      4. Lazard AJ , et al
      . Developing Pictorial Cigarillo Warnings: Insights From Focus Groups. Nicotine Tob Res 2021;23:383–9. doi:10.1093/ntr/ntaa130
      OpenUrlPubMed
    25. ↵
      2. Cornacchione Ross J ,
      3. Lazard AJ ,
      4. King JL , et al
      . Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults. Tob Control 2023;32:211–7. doi:10.1136/tobaccocontrol-2020-056288
      OpenUrlAbstract/FREE Full Text
    26. ↵
      2. Baig SA ,
      3. Noar SM ,
      4. Gottfredson NC , et al
      . UNC Perceived Message Effectiveness: Validation of a Brief Scale. Ann Behav Med 2019;53:732–42. doi:10.1093/abm/kay080
      OpenUrlCrossRefPubMed
    27. ↵
      2. Dillard JP ,
      3. Shen L ,
      4. Vail RG
      . Does Perceived Message Effectiveness Cause Persuasion or Vice Versa? 17 Consistent Answers. Human Comm Res 2007;33:467–88. doi:10.1111/j.1468-2958.2007.00308.x
      OpenUrl
    28. ↵
      2. Schneider S ,
      3. Gadinger M ,
      4. Fischer A
      . Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Educ Couns 2012;86:77–83. doi:10.1016/j.pec.2011.03.005
      OpenUrlCrossRefPubMed
    29. ↵
      2. Kowitt SD ,
      3. Jarman KL ,
      4. Cornacchione Ross J , et al
      . Designing More Effective Cigar Warnings: An Experiment Among Adult Cigar Smokers. Nicotine Tob Res 2022;24:617–22. doi:10.1093/ntr/ntab207
      OpenUrlPubMed
    30. ↵
      2. Cornacchione Ross J ,
      3. Kowitt SD ,
      4. Jarman KL , et al
      . Perceived message effectiveness of cigar warning themes among adults in the United States. Prev Med Rep 2023;34:102236. doi:10.1016/j.pmedr.2023.102236
    31. ↵
      2. Dunn DS ,
      3. Johnson AL ,
      4. Sterling KL , et al
      . Differences in reasons for little cigar/cigarillo use across white and black/African American young adult users. Addict Behav 2021;118:106884. doi:10.1016/j.addbeh.2021.106884
      OpenUrlPubMed
    32. ↵
      2. Avishai A ,
      3. Meernik C ,
      4. Goldstein AO , et al
      . Impact and mechanisms of cigarillo flavor descriptors on susceptibility to use among young adult nonusers of tobacco. J Applied Social Pyschol 2020;50:699–708. doi:10.1111/jasp.12706
      OpenUrl
    33. ↵
      2. Byron MJ ,
      3. Lazard AJ ,
      4. Peters E , et al
      . Effective Formats for Communicating Risks from Cigarette Smoke Chemicals. Tob Regul Sci 2018;4:16–29. doi:10.18001/TRS.4.2.2
      OpenUrlPubMed
    34. ↵
      2. Lazard AJ ,
      3. Byron MJ ,
      4. Vu H , et al
      . Website Designs for Communicating About Chemicals in Cigarette Smoke. Health Commun 2019;34:333–42. doi:10.1080/10410236.2017.1407276
      OpenUrlPubMed
    35. ↵
      2. Gammon DG ,
      3. Loomis BR ,
      4. Dench DL , et al
      . Effect of price changes in little cigars and cigarettes on little cigar sales: USA, Q4 2011-Q4 2013. Tob Control 2016;25:538–44. doi:10.1136/tobaccocontrol-2015-052343
      OpenUrlAbstract/FREE Full Text
    36. ↵
      2. Hall MG ,
      3. Sheeran P ,
      4. Noar SM , et al
      . A brief measure of reactance to health warnings. J Behav Med 2017;40:520–9. doi:10.1007/s10865-016-9821-z
      OpenUrlPubMed
    37. ↵
      2. Kees J ,
      3. Burton S ,
      4. Andrews JC , et al
      . Understanding how Graphic Pictorial Warnings Work on Cigarette Packaging. J Public Policy & Marketing 2010;29:265–76. doi:10.1509/jppm.29.2.265
      OpenUrlCrossRefWeb of Science
    38. ↵
      2. Noar SM ,
      3. Hall MG ,
      4. Francis DB , et al
      . Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 2016;25:341–54. doi:10.1136/tobaccocontrol-2014-051978
      OpenUrlAbstract/FREE Full Text
    39. ↵
      2. Fong GT ,
      3. Hammond D ,
      4. Hitchman SC
      . The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ 2009;87:640–3. doi:10.2471/blt.09.069575
      OpenUrlCrossRefPubMedWeb of Science
    40. ↵
      2. Vaish A ,
      3. Grossmann T ,
      4. Woodward A
      . Not all emotions are created equal: the negativity bias in social-emotional development. Psychol Bull 2008;134:383–403. doi:10.1037/0033-2909.134.3.383
      OpenUrlCrossRefPubMedWeb of Science
    41. ↵
      2. Brewer NT ,
      3. Parada H ,
      4. Hall MG , et al
      . Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts. Ann Behav Med 2019;53:232–43. doi:10.1093/abm/kay032
      OpenUrlCrossRefPubMed
    42. ↵
      2. Strasser AA ,
      3. Tang KZ ,
      4. Romer D , et al
      . Graphic warning labels in cigarette advertisements: recall and viewing patterns. Am J Prev Med 2012;43:41–7. doi:10.1016/j.amepre.2012.02.026
      OpenUrlCrossRefPubMed
    43. ↵
      2. Glenberg AM ,
      3. Langston WE
      . Comprehension of illustrated text: Pictures help to build mental models. J Mem Lang 1992;31:129–51. doi:10.1016/0749-596X(92)90008-L
      OpenUrlCrossRefWeb of Science
    44. ↵
      2. Stuber J ,
      3. Galea S ,
      4. Link BG
      . Smoking and the emergence of a stigmatized social status. Soc Sci Med 2008;67:420–30. doi:10.1016/j.socscimed.2008.03.010
      OpenUrlCrossRefPubMedWeb of Science
    45. ↵
      2. Emery S ,
      3. Aly EH ,
      4. Vera L , et al
      . Tobacco control in a changing media landscape: how tobacco control programs use the internet. Am J Prev Med 2014;46:293–6. doi:10.1016/j.amepre.2013.11.005
      OpenUrlPubMed
    46. ↵
      2. Weinstein ND
      . Accuracy of smokers’ risk perceptions. Ann Behav Med 1998;20:135–40. doi:10.1007/BF02884459
      OpenUrlCrossRefPubMedWeb of Science
    47. ↵
      2. Masiero M ,
      3. Lucchiari C ,
      4. Pravettoni G
      . Personal fable: optimistic bias in cigarette smokers. Int J High Risk Behav Addict 2015;4:e20939. doi:10.5812/ijhrba.20939
    48. ↵
      2. Wakefield M ,
      3. Germain D ,
      4. Durkin S , et al
      . Do larger pictorial health warnings diminish the need for plain packaging of cigarettes? Addiction 2012;107:1159–67. doi:10.1111/j.1360-0443.2012.03774.x
      OpenUrlCrossRefPubMedWeb of Science
    49. ↵
      2. Gantiva C ,
      3. Sotaquirá M ,
      4. Marroquín M , et al
      . Size matters in the case of graphic health warnings: Evidence from physiological measures. Addict Behav 2019;92:64–8. doi:10.1016/j.addbeh.2018.12.003
      OpenUrlPubMed
    50. ↵
      2. Clark SA ,
      3. Kowitt SD ,
      4. Jarman KL , et al
      . The Role of Harm Visibility for Pictorial Health Warning Labels on Cigars. Nicotine Tob Res 2024:ntae113. doi:10.1093/ntr/ntae113
    51. ↵
      2. Ranney LM ,
      3. Clark SA ,
      4. Jarman KL , et al
      . How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide. BMJ Open 2023;13:e062033. doi:10.1136/bmjopen-2022-062033
    52. ↵
      2. Jager KJ ,
      3. Zoccali C ,
      4. Macleod A , et al
      . Confounding: what it is and how to deal with it. Kidney Int 2008;73:256–60. doi:10.1038/sj.ki.5002650
      OpenUrlCrossRefPubMedWeb of Science
    53. ↵
      2. Pourhoseingholi MA ,
      3. Baghestani AR ,
      4. Vahedi M
      . How to control confounding effects by statistical analysis. Gastroenterol Hepatol Bed Bench 2012;5:79–83.
      OpenUrlPubMed

    Footnotes

    • Contributors Conceptualisation: all authors. Data curation: KJ. Formal analysis: KJ. Funding acquisition: AOG. Investigation: all authors. Methodology: CE, KJ. Project administration: KJ. Software: KJ. Supervision: LR, KJ. Visualisation: KJ. Roles/writing— original draft: MZY, AOG. Writing—review and editing: all authors. AOG is responsible for the overall content as the guarantor.

    • Funding This research was supported by the NCI and FDA Center for Tobacco Products (CPT) under Award Number R01CA240732.This research was supported by the NCI and FDA Center for Tobacco Products (CPT) under Award Number R01CA240732. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.