Do the Racial and Sex Characteristics of People Portrayed On Cigarette Package Pictorial Warning Labels Matter?

Theoretical Background and research questions/hypothesis: 

The U.S. Food & Drug Administration will create new pictorial health warning labels (PHWLs) for cigarette packaging which might include imagery of people with different racial and sex characteristics. However, concordance effects due to the similarity (or difference) of racial and sex characteristics of PHWL imagery and of smokers have not been studied.

Methods:  Field experiments were conducted with a convenience sample of 701 mostly low-income adult smokers (50.5% White, 49.5% African American; 41.8% male, 58.2% female) in South Carolina. Each participant evaluated in random order 2 to 8 cigarette packs displaying PHWLs that varied the race and sex of the person pictured in the PHWL and the smoking-related topic it addressed (e.g., cardiovascular disease, lung cancer). Participants rated PHWLs for salience, credibility, relevance, negative emotional response, and effectiveness.  To adjust for repeated observations, linear mixed effects (LME) models were estimated, wherein each PHWL response was regressed on participant race, PHWL race, and the interaction between them; on participant sex, PHWL sex, and the interaction between them; and on age, education, income, smoking intensity, quit attempts, quit intention, and PHWL topic.

Results:  African-American participants rated PHWLs significantly higher than White participants, regardless of the depiction of race in the PHWLs. For example, African-American participants rated PHWLs that depicted a White person as more salient (8.18 vs 7.11, p < 0.000), credible (8.63 vs 7.95, p < 0.000), relevant (7.93 vs 6.62, p < 0.000), negatively arousing (8.05 vs 6.92, p < 0.000), and effective (8.04 vs 6.43, p < 0.000). African-American participants also rated PHWLs that depicted an African-American as more salient (7.34 vs 5.79, p < 0.000), credible (7.74 vs 6.58, p < 0.000), relevant (7.19 vs 5.34, p < 0.000), negatively arousing (6.95 vs 5.34, p < 0.000), and effective (7.06 vs 5.12, p < 0.000). For all PHWL responses, statistically significant interactions between participant race and PHWL race were found, indicating that the difference was greatest when African-American participants rated PHWLs that depicted African Americans. There were no significant differences between male and female participants when they rated PHWLs that depicted a man. However, compared to female participants, male participants rated the PHWLs with woman in the images as more relevant (7.3 vs 6.9, p = 0.006) and producing stronger negative emotional arousal (7.49 vs 7.1, p= 0.007). In multivariate models for all PHWL response variables, no main or interaction effects were found when examining sex, except for the main effect of male smokers having somewhat stronger negative emotional response than female smokers.

Conclusions:  Concordance of sex characteristics of smokers and people depicted in PHWLs  do not appear to produce greater  effects than when these characteristics differ. However, racial concordance appears to influence smokers’ responses to PHWLs.

Implications for research and/or practice:  PHWLs that depict racial characteristics are likely to produce differential effects, and multiple PHWLs with diverse imagery or with imagery that does not depict racial characteristics may be necessary to produce the greatest impact across smoker subpopulations. Future research should determine whether concordance influences cessation outcomes.