Plenty of evidence shows well-designed health warnings and messages are part of a range of effective measures to communicate health risks and increase the motivation of tobacco users to quit and decrease their tobacco consumption (1-4). Thus, Article 11 of the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) pointed out the requirement of packaging and labelling of tobacco products (5). After the FCTC came into force, health warnings on cigarette packaging in China had been changed in three rounds. In January 2009 (6), plain text health warnings were required to account for 30% of the front, back, and bottom area of the cigarette packaging, including two general warnings. The warning information on the back of the cigarette pack was required to be in English. In April 2012 (7), the text warning on the back of the cigarette pack was adjusted from English to Chinese; the font size was doubled (the height of text was required to be not less than 4 mm), but the overall size of the warning did not change. In October 2016 (8), a new version of the text health warning took effect, requiring the area of the warning to reach 35% of the cigarette pack. The font requirement was changed to 4.5 mm and three new text warnings were added. This study examined the effects of current health warning labels on smoking cessation intention and explored the different influence between the current health warning label and pictorial health warning labels.
Data used in this paper were from the Global Adult Tobacco Survey (GATS) China Project, which used a global standardized methodology and was conducted in 2018 (9). A multi-stage, geographically clustered sample design was used to produce nationally representative data. In total, 200 monitoring counties/districts were sampled coming from 31 provincial-level administrative divisions (PLADs) of the mainland of of China. Nationally, a total of 24,370 households were sampled and one individual was randomly selected from each participating household to complete the survey. The household survey method was adopted, and the investigator used the digital tablet to collect data through in-person inquiry. The subjects of this survey were the Chinese residents aged 15 and above who used the household as their primary residence in the previous month before the survey and excluded those who lived collectively in places like student dormitories, nursing homes, military camps, prisons, or hospitals.
All of the participants were asked “In the last 30 days, did you notice any health warnings on cigarette packages?”, and smokers were asked “In the last 30 days, have warning labels on cigarette packages led you to think about quitting?”. Then the digital tablet will randomly present five imitated pictorial health warnings and ask smokers “If you see such a health warning on a cigarette package, would you consider stopping smoking?” In addition, all of the participants were asked “Do you support printing such a pictorial warning on cigarette packages?” As showed in Figure 1, pictorial health warning 1 was “Smoking and secondhand smoke cause lung cancer” and used pictures of lungs of non-smokers and smokers for comparison. Pictorial health warning 2 was “Smoking causes chronic obstructive pulmonary disease (COPD)” with a picture of an actual patient with COPD caused by smoking. Pictorial health warning 3 was “Smoking causes the yellowing of teeth, bad breath, and periodontal disease” using a picture of diseased teeth and gum. Pictorial health warning 4 was “Smoking causes erectile dysfunction” using curved cigarettes to symbolize the symptom. Pictorial health warning 5 was “Smoking causes peripheral vascular diseases” using a picture of a diseased foot from a patient.
Due to the complex survey sample design for the surveys, each responding unit was assigned a unique survey weight that was used to produce estimates of population parameters, and 2018 population data were used for post-stratification, which was provided by National Statistics Bureau of China. All computations were performed using the SAS software (version 9.4, SAS Institute Inc., Cary, USA) complex survey data analysis procedure. Percentage or proportion was used for descriptive statistics. The difference of values with no overlap in confidence interval(CI) was identified to be statistically significant between subgroups.
Out of a total of 24,370 selected households, 3,193 empty households were eliminated and 21,177 remained. Out of these, 19,640 households completed the survey and a total of 19,376 people completed the final individual survey. The overall response rate was 91.5%. The 19,376 people surveyed represented a total of 1,156,987,000 men and women aged 15 and over in the mainland of China. There were 9,109 men and 10,267 women in the sample, representing 50.6% of men and 49.4% of women in the target population, respectively. In terms of age distribution, there were 930, 5,128, 8,652, and 4,666 respondents in the 15–24, 25–44, 45–64, and ≥65 years old groups, respectively.
The results showed that within the 30 days prior to the survey, 88.2% of smokers had seen the health warnings on the cigarette package, within whom 36.3% said that they would consider quitting smoking because they saw the current health warnings on the cigarette package. In addition, the proportion of non-smokers who saw the health warning on the cigarette packaging was 53.4%. The percentage of people who saw the health warnings on cigarette packaging was highest among young people (15–24 years old), both among smokers (98.1%) and non-smokers (64.5%).
The results showed that 56.1% of smokers said they would consider quitting smoking after seeing such pictorial health warnings, which was much higher than seeing the current health warnings on the cigarette package. For each age group, the proportion of smokers considering quitting after seeing the pictorial health warning labels were higher than those who saw current health warning labels. This was also true for smokers with different education levels, and smokers living in urban and rural areas (Table 1).
Demographic characteristics Non-smokers who noticed health warnings on cigarette package [percentage (95%CI)] Current smokers* [percentage (95%CI)] Noticed health warnings on cigarette package Thought about quitting because of warning labels Thought about quitting because of pictorial health warnings Overall 53.4(50.9−55.9) 88.2(86.2−90.0) 36.3(33.5−39.2) 56.1(52.5−59.6) Gender Male 59.2(55.8−62.6) 88.9(86.9−90.7) 36.2(33.4−39.1) 56.2(52.6−59.8) Female 50.3(47.7−52.9) 70.7(61.9−78.1) 38.4(27.7−50.4) 52.9(41.3−64.1) Age (years) 15–24 64.5(59.5−69.2) 98.1(93.6−99.5) 30.3(22.2−39.9) 59.3(48.4−69.3) 25–44 64.0(60.2−67.6) 91.4(88.3−93.8) 40.1(36.2−44.1) 60.1(55.2−64.9) 45–64 46.8(44.0−49.7) 86.6(84.2−88.8) 35.8(32.6−39.1) 54.8(50.9−58.6) ≥65 28.7(26.3−31.2) 74.8(70.6−78.6) 29.3(24.6−34.6) 45.1(39.2−51.2) Residence Urban 56.3(53.5−59.0) 92.2(90.5−93.7) 32.6(29.4−36.0) 52.9(48.3−57.5) Rural 48.8(44.4−53.1) 83.0(79.1−86.4) 41.5(37.1−46.1) 61.4(56.5−66.1) Education level Primary school or less 32.4(29.7−35.3) 75.1(71.6−78.4) 33.7(29.5−38.3) 51.3(46.5−56.1) Attended secondary school 62.0(58.0−65.9) 91.0(87.9−93.3) 38.5(34.4−42.9) 58.7(54.2−63.0) High school graduate 64.0(60.1−67.8) 92.8(90.0−94.9) 38.5(33.4−43.7) 56.7(50.3−63.0) College graduate or above 57.2(53.5−60.9) 94.2(89.7−96.8) 36.1(30.1−42.5) 55.4(48.2−62.3) Abbreviation：CI=confidence interval.
*Includes daily and occasional (less than daily) smokers.
Table 1. Percentage of adults aged 15 years or older who noticed health warnings on cigarette packages and considered quitting because of the different health warnings.
In addition, the proportions of smokers who considered quitting smoking after seeing pictorial health warnings varied based on which image they saw. The proportion of smokers who intended to quit smoking after seeing the pictorial warning of “Smoking causes chronic obstructive pulmonary disease” was the highest among the 5 pictorial health warning labels (61.9%); while “Smoking causes erectile dysfunction” had the lowest rate (49.3%). Between them were “Smoking and second-hand smoke cause lung cancer”, “Smoking causes peripheral vascular diseases”, and “Smoking causes the yellowing of teeth, bad breath, and periodontal disease”, which had a rate of 58.2%, 55.8%, and 54.9%, respectively. Compared with the other 4 pictorial health warnings, fewer smokers wanted to quit after seeing the “Smoking causes erectile dysfunction”, which used a symbolic image rather than graphic depictions of the syndrome.
The results also showed that 69.6% of the subjects supported the printing of pictorial health warnings on cigarette packaging including 65.2% of smokers and 71.1% of non-smokers.