UC San Diego

Background: The United States (US) is the only high-income country that has not mandated Graphic Warning Labels (GWLs) on cigarette packaging. Pack imagery is a key element of tobacco marketing aimed at generating brand appeal to encourage continued smoking. Removing industry imagery should neutralize reactions to packaging thus lessening appeal and weakening the product’s perceived value. Adding GWLs should go further and replace appeal with aversion thus generating negative responses and subtracting from perceived valuations. Methods: This dissertation consists of three studies using data from the CASA randomized controlled trial examining the effects of cigarette packaging on smoking cognitions and behavior. Study 1 quantified smokers’ initial reactions as they examined packaging design options (i.e., own US pack, Blank pack devoid of industry imagery, and three GWL plain packs). Study 2 evaluated the psychometric properties of a 6-item measure of brand appeal for cigarette packaging. Study 3 identified the change in smokers’ appeal-aversion valuations via a willingness-to-pay assessment of packaging options after randomization to a 3-month intervention involving smokers purchasing their cigarettes repackaged into one of three pack options. Results: Smokers had largely positive reactions to their own packs, neutral reactions to the blank pack, and graded negative reactions to GWL packs that aligned with expressions of disgust, anger, fear, and sadness. Strong scalability, internal consistency, concurrent validity, and predictive validity was found for the brand appeal measure. We found upfront positive valuations (i.e., appeal) for smokers’ Own Packs, weakened yet still positive valuations for the Blank Pack, and negative valuations (i.e., aversion) for GWLs. After 3-month exposure, minimal change in willingness-to-pay was observed: appeal-aversion valuations did not change among those randomized to use their own packs, while those randomized to use Blank and GWL packs were less price aversive to GWL imagery that provoked high negative affect. Conclusion: The findings indicate that industry-designed packaging generates appeal and positive affect among adult US daily smokers. Removing industry imagery temporarily neutralizes this response and adding GWLs engenders aversion and negative affect which may decrease following repeated exposure. Plain GWL packaging would seem to be an important component of an effective tobacco control strategy.