Creating Synergies Between Pictorial Warning Labels On Cigarette Packages and Media Campaigns: A Case Study of Mexico

Theoretical Background and research questions/hypothesis:  In September 2010, Mexico implemented pictorial health warning labels (HWLs) on cigarette packages.  Previous research suggests that pictorial HWLs influence the psychosocial factors that predict quitting among adult smokers. However, no research has examined among adult smokers the potentially synergistic effect of a media campaign linked to pictorial HWL content.  This study aimed to assess the main and interactive effects of pictorial HWLs and a linked media campaign in Guadalajara, Mexico.  

Methods: Cross-sectional data were collected from a population-based sample of 1786 adult smokers, aged 18 to 55, in Guadalajara.  Data collection started three weeks after cigarette packs with pictorial HWLs began to enter the market and three weeks after the media campaign was started.  Recall of the campaign and pictorial HWLs was determined by showing participants pictures of the HWLs or the visual campaign PSAs (recall of the radio ad was measured with a brief description of ad content).  Questions also asked about attention and impact of HWLs, knowledge related to HWL and campaign content, perceived credibility and fairness of the HWLs, and quit-related thoughts and behaviors during the campaign period.  Logistic and linear regression models were estimated to determine the main and interaction effects of recall of pictorial warning labels and the campaign on key outcomes.

Results: In bivariate and multivariate adjusted models, recall of pictorial HWLs and of the campaign were positively associated with greater noticing and reading of warning labels, whereas only pictorial HWL exposure was associated with the frequency of thinking about health risks and quitting smoking due to HWLs.  Both recall of pictorial HWLs and recall of the campaign were independently associated with greater perceived credibility of the warning labels, greater knowledge of toxic tobacco constituents and greater knowledge of harms from secondhand smoke exposure.  Recall of neither campaign was associated with peceptions of HWLs as unfair.  Campaign recall was associated with greater frequency of thoughts about quitting and smoking dangers, whereas the association was significant but weaker among those exposed to pictorial HWLs.   Nevertheless, recall of pictorial HWLs was associated with greater likelihood of having attempted to quit during the campaign period (7% vs. 14%), whereas campaign recall was not. 

Conclusions: These results suggest that the new pictorial warning labels on cigarette packages in Mexico have had a greater impact than the previous text only warning labels on knowledge and attitudes associated with quitting, as well as on quit behavior itself.  Smokers who recalled either the pictorial HWLs or the campaign were more likely than people who did not recall them to perceive warning labels as credible, but no more likely to perceive them as unfair towards smokers.  In general, recall of the media campaign produced independent additive effects on key variables related to campaign content.   

Implications for research and/or practice: Results from this study indicate the pictorial warnings are more effective than textual warnings, and that media campaigns can enhance their effectiveness.  The Food and Drug Administration, as well as other federal and local agencies, should consider developing and disseminating media campaigns that are linked to new pictorial warning labels in the US.