Investigating the effectiveness of pictorial health warnings in Mauritius: findings from the ITC Mauritius survey

Introduction: Health warnings on tobacco packages are an effective strategy for informing the public about the harms associated with tobacco use. Most studies investigating the effectiveness of pictorial health warnings (PHWs) on cigarette packages are from high-income countries. This study evaluated the impact of PHWs on smokers' perceptions and behavior in Mauritius, the first country in the World Health Organization African region to implement PHWs.

Methods: Data were drawn from 3 waves of a nationally representative cohort of adult smokers from the International Tobacco Control (ITC) Mauritius Survey (n = 668). Wave 1 was conducted in 2009, 6 months prior to the implementation of PHWs. Waves 2 and 3 were conducted 10-12 months and 20-21 months, respectively, postimplementation. Six established indicators of warning effectiveness were used to evaluate the effect of PHWs on smokers' perceptions and behavior.

Results: All indicators of warning effectiveness (salience, cognitive, and behavioral reactions) and the Label Impact Index, a weighted combination of 4 indicators, increased significantly between Waves 1 and 2. However, between Waves 2 and 3, there was a significant decline in the proportion of smokers who reported "avoiding looking" at labels.

Conclusions: This study found that implementation of PHWs in Mauritius significantly enhanced the effectiveness of warnings, illustrating their value for other countries, particularly in Africa, at an early stage in tobacco control. The study also demonstrates the importance of revising PHWs to counteract wearout. The introduction of PHWs in Mauritius clearly demonstrates the benefits of employing an evidence-based approach to strengthen tobacco control policies.