Do larger graphic health warnings on standardised cigarette packs increase adolescents’ cognitive processing of consumer health information and beliefs about smoking-related harms?

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To examine the impact of plain packaging of cigarettes with enhanced graphic health warnings on Australian adolescents’ cognitive processing of warnings and awareness of different health consequences of smoking.


Cross-sectional school-based surveys conducted in 2011 (prior to introduction of standardised packaging, n=6338) and 2013 (7–12 months afterwards, n=5915). Students indicated frequency of attending to, reading, thinking or talking about warnings. Students viewed a list of diseases or health effects and were asked to indicate whether each was caused by smoking. Two—‘kidney and bladder cancer’ and ‘damages gums and teeth’—were new while the remainder had been promoted through previous health warnings and/or television campaigns. The 60% of students seeing a cigarette pack in previous 6 months in 2011 and 65% in 2013 form the sample for analysis. Changes in responses over time are examined.


Awareness that smoking causes bladder cancer increased between 2011 and 2013 (p=0.002). There was high agreement with statements reflecting health effects featured in previous warnings or advertisements with little change over time. Exceptions to this were increases in the proportion agreeing that smoking was a leading cause of death (p<0.001) and causes blindness (p<0.001). The frequency of students reading, attending to, thinking or talking about the health warnings on cigarette packs did not change.


Acknowledgement of negative health effects of smoking among Australian adolescents remains high. Apart from increased awareness of bladder cancer, new requirements for packaging and health warnings did not increase adolescents’ cognitive processing of warning information.

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