Research reveals most effective images for cigar health warning labels

The University of North Carolina at Chapel Hill Tobacco Prevention and Evaluation Program (TPEP) recently published a study in the journal Nicotine and Tobacco Research discussing the effectiveness of pictorial health warning labels as proven tools for communicating the dangers of tobacco product use.

Little research has been conducted on the effectiveness of health warning labels for cigars specifically. The study, led by Sonia Clark, MHA, sought to address this gap by identifying the most effective types of images to pair with newly developed cigar health warning labels.

Cigar smoking remains a significant public health concern in the United States, with nearly 9 million adults regularly using various types of cigars. Despite the known health risks associated with cigar smoking, including lung cancer, heart disease, and oral cancers, effective communication of these risks through warning labels has been challenging.

The research—conducted through an online survey experiment in September 2021 with 753 US adults who reported using little cigars, cigarillos, or large cigars in the most recent 30 days—aimed to identify the most effective types of images to pair with newly developed cigar health warning labels. Participants were shown different levels of harm visibility, including images depicting internal harm (e.g., diseased organs), external harm visible outside the body (e.g., a person clutching their chest to represent a heart attack), or a combination of both internal and external harm.

Results revealed that warnings with images depicting both internal and external harm, or external harm alone, significantly outperformed images depicting only internal harm across all measured outcomes. These findings provide crucial insights for future cigar health warning label development, suggesting that images portraying visible external harm are particularly impactful in conveying the dangers of cigar smoking.

Study co-author Kristen Jarman, MPH, states, "Our findings show that including two images showing harm that is both internal and external to the body or one image of external health effects seems to be promising, compared with showing an image of internal harm alone. It opens up interesting questions about whether we should consider including more than one image in warnings to better communicate the harms of smoking."

These results have important implications for regulatory agencies, particularly the US Food and Drug Administration (FDA), which has proposed text-only warning labels for cigars. The study suggests that incorporating pictorial warnings depicting both internal and external harm, or external harm alone, could significantly improve warning effectiveness and ultimately contribute to reducing cigar-related harm.

Clark states, "Health warning labels are a cost-effective way to educate people about the health risks of smoking cigars. Unfortunately, the current warning labels on cigars are often small and text-only. Our research study is important because it provides evidence on types of images that may be persuasive in cigar warning labels."

The study represents a significant step forward in tobacco control research and underscores the importance of evidence-based approaches in public health interventions. As efforts continue to combat the tobacco epidemic, insights from studies like this pave the way for more effective communication strategies and ultimately contribute to improved public health outcomes.

Members from UNC Family Medicine's Tobacco Prevention and Evaluation Program included in this study are Sonia Clark, MHA, Research Specialist; Sarah Kowitt, Ph.D., MPH, Assistant Professor; Kristen Jarman, MSPH, Associate Director for Tobacco Prevention and Evaluation Program; Leah Ranney, Ph.D., MA, Director for Tobacco Prevention and Evaluation Program; and Adam Goldstein, MD, MPH, Director of UNC Tobacco Intervention Programs.