Systematic review of measures used in pictorial cigarette pack warning experiments

Diane B. Francis, Marissa G. Hall, Seth M. Noar, Kurt M. Ribisl, Noel T. Brewer

Research output: Contribution to journalReview articlepeer-review

23 Scopus citations


Background: We sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments and provide recommendations for future studies. Methods: Our systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity. Results: We identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly used outcomes were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Of 68 studies, 37 (54%) mentioned a theory as informing the study. Conclusions: Our review found great variability in constructs and measures used to evaluate the impact of cigarette pack pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources. Implications: Robust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for standardized, theory-based measures.

Original languageEnglish
Article numberntx082
Pages (from-to)1127-1137
Number of pages11
JournalNicotine and Tobacco Research
Issue number10
StatePublished - Oct 1 2017

Bibliographical note

Funding Information:
Research reported in this publication was supported by The National Cancer Institute and FDA Center for Tobacco Products (CTP) under Award Numbers P30CA016086-38S2 and 1P50CA18090701. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. The work was also supported by a seed grant from the School of Media and Journalism at UNC Chapel Hill.

Publisher Copyright:
© The Author 2017. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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