Relative efficacy of cigarillo warning statements in text and pictorial formats: An experimental study among a sample of US young adults

Introduction: Health warning labels (HWLs) communicate the health risks of cigar use and can decrease use when on cigar packages. This study assessed the relative efficacy of six FDA-proposed individual warning statements in text and pictorial format.

Methods: A sample of young adults (ages 18-29) were randomized to a text or pictorial warning condition on generic cigarillo packages. The warning statements were about lung cancer and heart disease; cancers of the mouth and throat; secondhand smoke; not a safe alternative; nicotine/addiction; and harm to baby. Negative emotional reactions, cognitive elaboration, and perceived message effectiveness (PME) were assessed for each warning using linear mixed models.

Results: Of the 661 participants, 47.3% reported ever cigarillo smoking, 32.7% current smoking, and 20% were susceptible. In the pictorial format, cancers of the mouth and throat elicited lower levels of anxiety compared to secondhand smoke, not a safe alternative, nicotine/addiction, and harm to baby (ps<0.001). Pictorial HWLs with human imagery induced high anxiety, sadness, fear, and guilt reactions (p<0.001) and higher PME (p=0.011) compared to pictorial HWLs with diseased body parts. Compared to the text HWL cancers of the mouth and throat, the text HWL harm to baby elicited higher anxiety (p=0.003), sadness (p=0.002) and PME (p<0.001).

Conclusions: Pictorial HWLs depicting people or human imagery, rather than images of diseased organs or body parts, to represent health effects elicited the most negative emotional reactions, such as anxiety and guilt, and higher PME. Including such images and texts highlighting effects on vulnerable populations like babies can better communicate cigarillo health risks, aiming to curb cigarillo use among young people.

Implications: The study suggests that pictorial health warning labels (HWLs) with human imagery significantly enhance the communication of cigarillo smoking risks compared to images of diseased organs. These HWLs evoke stronger emotional responses, particularly anxiety and guilt, and higher perceived message effectiveness by depicting a recognizable person. Furthermore, text-only warnings describing the smoking effect on vulnerable populations such as babies might have a higher impact on young adults. This evidence supports a strategic shift in FDA policies to include such impactful images and texts, which could potentially lead to a significant reduction in cigarillo use among young people. Our findings underscore the urgent need for continued research and implementation of these enhanced warning labels to improve public health outcomes.