We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior A Randomized Clinical Trial

Noel T. Brewer, PhD1,2; Marissa G. Hall, MSPH1,2; Seth M. Noar, PhD2,3; Humberto Parada, MPH4; Al Stein-Seroussi, PhD5; Laura E. Bach, MPH1; Sean Hanley, PhD5; Kurt M. Ribisl, PhD1,2
[+] Author Affiliations
1Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
3School of Media and Journalism, University of North Carolina, Chapel Hill
4Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
5Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
JAMA Intern Med. 2016;176(7):905-912. doi:10.1001/jamainternmed.2016.2621.
Text Size: A A A
Published online

Importance  Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain.

Objective  To assess the effect of adding pictorial warnings to the front and back of cigarette packs.

Design, Setting, and Participants  This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events.

Interventions  We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General’s warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act’s required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs).

Main Outcomes and Measures  The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General’s warning.

Results  Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting.

Conclusions and Relevance  Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking.

Trial Registration  clinicaltrials.gov Identifier: NCT02247908

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Place holder to copy figure label and caption
Figure 1.
Warnings Used in the Trial
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Trial Enrollment, Randomization, and Retention
Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment
Potential Effect of Economic Warnings
Posted on June 13, 2016
Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine
Conflict of Interest: None Declared
I congratulate the authors for their efforts in this invaluable field, smoking cessation. Demographic data of this trial indicate that more than half of the study participants had low income (<150% of federal poverty level). I wonder if pictorial warnings regarding problems associated with the economic burden of smoking could result in increased rates of smoking cessation attempts.
Design on cigarette package in Norway
Posted on July 16, 2016
Valerie Heemstra, D.O.
Innovative Health Systems, White Plains, NY 10603
Conflict of Interest: None Declared
While visiting Norway in 2006, I saw a cigarette package on the ground with a design of a large skull and crossbones. The effect on me (a non-smoker) was shocking, and hopefully deterred at least some smokers. On the same trip, I noted chargers for electric cars on a street in Oslo. A Norwegian woman with breast cancer told me that she lives on Long Island in New York because care for breast cancer was better (in 2006) in the U.S., but encourages her daughter to continue to live in Norway, because all other healthcare in Norway was cheaper and just as good as in America, especially for young families. Thought-provoking anecdotes implying Norway may be a few steps ahead of the U.S. in some regards.
Respect the Rights of Disabled People
Posted on July 22, 2016
Dr. Med. Andreas Schnitzler
Facharzt für Innere Medizin und Nephrologie
Conflict of Interest: None Declared

It is completely irrelevant whether deterrent pictures of ill and disabled people are effective, because they violate the rights of disabled people in the sense of human dignity:

"I consider the anti-smoking campaign by deterring images to be useful, but I object against providing smoking in direct relation to disability as a result of smoking. For example, there is a warning, smoking causes strokes and disability, accompanied by images of a pale, apathetic, in the wheelchair hanging woman or an artificially ventilated man in the hospital bed. These subjects provide a stereotyped and negative image of disability, which I regard as discriminatory“ (1). 

The Austrian Deputy Dr. Huainigg is a ventilated wheelchair user.

Subsequently, these images were taken back for Austria (2), and referred to the "European Disability Forum“.

It must be seriously asked why these considerations were never taken into account.


(1) https://www.bizeps.or.at/huainigg-behinderung-als-abschreckung-ist-nicht-akzeptabel/; accessed 19.07.2016

(2) https://www.bizeps.or.at/schockbilder-auf-zigarettenpackungen-sollen-vom-rauchen-abhalten/; accessed 19.07.2016

Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles