The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies

Seth M. Noar, Diane B. Francis, Christy Bridges, Jennah M. Sontag, Kurt M. Ribisl, Noel T. Brewer

Research output: Contribution to journalReview articlepeer-review

229 Scopus citations


Objectives Cigarette pack warnings are a tobacco control strategy used globally. To understand their impact, we systematically reviewed longitudinal observational studies examining national implementation of strengthened warnings. Methods We used comprehensive search procedures to identify observational studies examining the impact of strengthening cigarette pack warnings. We report longitudinal changes in knowledge, beliefs, attitudes, intentions, and behavior. Results We identified 32 studies conducted in 20 countries with 812,363 participants. Studies commonly examined changes from text to pictorial warnings (64%); the remainder examined strengthened text or strengthened pictorial warnings. Knowledge increased in all 12 studies that assessed it. Studies of beliefs/attitudes and intentions showed mixed results. Quitline calls increased in four of six studies, while foregoing of cigarettes did not increase. Cigarette consumption decreased in three of eight studies; quit attempts increased in four of seven studies; and short-term cessation increased in two of three studies. Smoking prevalence decreased in six of nine studies. Conclusions Strengthening warnings was associated with longitudinal increases in knowledge, quitline calls and reductions in smoking behavior. Strengthening warning policies should be a priority for tobacco control globally.

Original languageEnglish
Pages (from-to)118-129
Number of pages12
JournalSocial Science and Medicine
StatePublished - Sep 1 2016

Bibliographical note

Publisher Copyright:
© 2016 The Authors


  • Graphic
  • Observational
  • Pictorial
  • Smoking
  • Theory
  • Warning

ASJC Scopus subject areas

  • Health(social science)
  • History and Philosophy of Science


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