Size matters in the case of graphic health warnings Evidence from

Addictive Behaviors 92 (2019) 64–68
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Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh
Size matters in the case of graphic health warnings: Evidence from
physiological measures
T
⁎
Carlos Gantivaa, , Miguel Sotaquiráa, Marisol Marroquína, Camilo Carnéa, Lisbeth Paradaa,
Miguel A. Muñozb
a
b
Universidad de San Buenaventura, Bogotá, Colombia
Universidad de Granada, Granada, Spain
H I GH L IG H T S
health warnings with the minimum size that is recommended by the World Health Organization did not increase any physiological measures that are
• Graphic
indices of arousal and aversive motivation.
health warnings that covered 60% of the cigarette pack increased the skin conductance response, corrugator muscle activity, and startle reflex compared
• Graphic
with cigarette packs without GHWs.
significant differences were found between nonsmokers, weekly smokers, and daily smokers in any of the physiological measures.
• No
• Increasing the minimum size of GHWs may better prevent cigarette smoking and facilitate smoking cessation.
A R T I C LE I N FO
A B S T R A C T
Keywords:
Graphic health warnings
Size
Tobacco
Emotion
Motivation
Objectives: > 50 countries use graphic health warnings (GHWs) with the minimum size that is recommended by
the World Health Organization (WHO). The aim of the present study was to evaluate the effect of the size of
GHWs on physiological responses that serve as indices of arousal and aversive motivation in nonsmokers, weekly
smokers, and daily smokers.
Methods: The skin conductance response, corrugator muscle activity, and startle reflex were recorded in 35
nonsmokers, 35 weekly smokers, and 35 daily smokers while they observed pictures of cigarette packs without
GHWs, cigarette packs with GHWs that covered 30% of the pack, and cigarette packs with GHWs that covered
60% of the pack.
Results: Cigarette packs with 30% GHWs did not generate significantly higher responses on any of the physiological measures compared with cigarette packs without GHWs. Conversely, cigarette packs with GHWs that
covered 60% of the pack generated a greater skin conductance response, greater corrugator muscle activity, and
an increase in the startle reflex compared with cigarette packs without GHWs. No significant differences were
found between groups in any of the physiological measures.
Conclusions: The minimum size of GHW that is recommended by the WHO is insufficient to generate an emotional response that favors avoidance of the cigarette pack. GHW that cover 60% of the cigarette pack significantly reduced the attractiveness of the tobacco packaging and generated greater arousal responses.
1. Introduction
Approximately 6 million people die every year from tobacco use
worldwide. > 5 million of these deaths result from direct tobacco use,
and > 600,000 nonsmokers dies because of exposure to tobacco smoke
(World Health Organization [WHO], 2016). This led the World Health
Organization (WHO) to develop a set of six measures, referred to as
⁎
MPOWER, that seek to reduce tobacco demand. The objective of these
measures is counteracting advertising, preventing the initiation of tobacco consumption, and encouraging abandonment of the habit
(Mackay, Bettcher, Minhas, & Schotte, 2012).
One strategy that was contemplated in MPOWER is the use of
warning images on tobacco packaging, with the aim of reducing the
attractiveness of the packaging and providing information on the
Corresponding author at: Universidad de San Buenaventura, Department of Psychology, Cr 8 H # 172-20, Bogotá, Colombia.
E-mail address: cgantiva@usbbog.edu.co (C. Gantiva).
https://doi.org/10.1016/j.addbeh.2018.12.003
Received 26 July 2018; Received in revised form 30 October 2018; Accepted 4 December 2018
Available online 07 December 2018
0306-4603/ © 2018 Elsevier Ltd. All rights reserved.
Addictive Behaviors 92 (2019) 64–68
C. Gantiva et al.
that emotional and motivational responses to tobacco-related cues and
GHWs change between different categories of smokers. For example,
Cui et al. (2012) found inhibition of the startle reflex in response to
tobacco-related pictures in heavy smokers compared with light smokers. Munafò, Roberts, Bauld, and Leonards (2011) found greater visual
attention toward GHWs on plain packs in nonsmokers and weekly
smokers compared with daily smokers. These results suggest a differential pattern of emotional and attentional responses to tobacco-related
cues (e.g., cigarette packs) and GHWs between weekly and daily smokers.
With regard to the size of GHWs, 57 countries use GHWs with the
minimum size that is recommended by the World Health Organization
[WHO] (2013). No studies have evaluated physiological measures to
determine whether this size is sufficient to generate a higher arousal
response, reduce attractiveness of the package, and generate a defensive motivational response that is associated with avoidance of the cigarette pack. Therefore, the objective of the present study was to
evaluate the effects of the size of GHWs and smoking status on physiological responses that are indicative of arousal and aversive motivation in nonsmokers, weekly smokers, and daily smokers.
One of the main goals of GHWs is to decrease the attractiveness of
tobacco packs (World Health Organization [WHO], 2013). A significant
increase in corrugator muscle activity and the startle reflex would be
expected when the cigarette pack has a GHW. A significant increase in
the SCR (i.e., an increase in the arousal response) would also be expected. Our goal was to determine whether the minimum size of GHWs
that is recommended by the WHO is sufficient to generate an emotional
response that favors avoidance of the cigarette pack.
consequences of consumption (World Health Organization [WHO],
2005). This strategy has proven effective in a wide range of demographic groups (Hammond et al., 2012; Hammond, Reid, Driezen, &
Boudreau, 2012; Thrasher et al., 2012), particularly in people who have
recently started tobacco consumption and people who seek to quit
smoking, especially when warnings are highly visible and display the
negative health effects of smoking (Hammond, Fong, McNeill, Borland,
& Cummings, 2006). However, the effectiveness of such images was
assessed using telephone surveys and only pictorial stimuli (that is
without including tobacco packages and image dimensions used in “real
world” packages).
Several studies have found that tobacco-related cues (e.g., cigarette
packs) generate activation of the appetitive motivational system and
high arousal, thus favoring approach behavior (Cinciripini et al., 2006;
Cui et al., 2012; Gantiva et al., 2015). Therefore, the effectiveness of
GHWs depends on their ability to elicit an aversive emotional response
and activate the defensive motivational system to discourage consumption and generate behavior that elicits avoidance of the pack.
Studies on the emotional impact of GHWs have generally been designed
using self-report measures. The results have shown that GHWs are
generally evaluated as aversive (Nascimento et al., 2008), but GHWs
are also sometimes assessed as neutral or even appetitive (Muñoz et al.,
2013). This conflicts with the objective of discouraging smoking by
decreasing the attractiveness of cigarette packs.
With regard to the size of GWHs, studies that have employed selfreport measures reported that the minimum size of GHWs that is recommended by the World Health Organization [WHO], 2005; (i.e., 30%
coverage of the cigarette pack) is insufficient to generate an emotional
impact that is associated with avoidance of the pack, especially in
smokers (Gantiva et al., 2016). However, one limitation of these studies
is that they were all performed using self-report measures of emotion.
None of the studies used physiological measures as objective indicators
of emotional impact.
The use of peripheral physiological responses as objective indices of
emotional and motivational responses has been extensively reported in
previous studies (Bradley, Codispoti, Cuthbert, & Lang, 2001). For example, the skin conductance response (SCR) is a reliable indicator of
arousal and orientation responses. Corrugator muscle activity is an indicator of aversive valence, and the amplitude of the startle reflex is an
index of appetitive or aversive valence (Bradley, 2009; Bradley et al.,
2001; Campbell, Wood, & McBride, 1997).
Muñoz, Gantiva, and Ciria (2016) recently utilized physiological
measures and found lower corrugator muscle activity in response to
GHWs that are used in the European Union compared with aversive
pictures from the International Affective Picture System (IAPS), suggesting that some of GHWs are not sufficiently disturbing to generate
strong aversive emotions. Newman-Norlund et al. (2014) utilized
functional magnetic resonance imaging on a population of 50 adult
smokers and found that GHWs elicited activation in a broad network of
brain areas that are associated with visual processing and emotion, but
this response was attenuated by repeated exposure to these stimuli.
These aforementioned studies had two principal limitations: (i)
neither study evaluated the effect of the size/coverage of GHWs on the
emotional response, and (ii) both studies compared only the emotional
response between nonsmokers and smokers. Several studies have found
2. Methods
2.1. Participants
A convenience sample of 105 participants was divided into three
groups: nonsmokers (n = 35, defined as never having smoked > 100
cigarettes in their lifetime and not currently smoking), weekly smokers
(n = 35, defined as smoking at least one cigarette per week but not
daily), and daily smokers (n = 35, defined as smoking at least one cigarette per day; Munafò et al., 2011). The sample was collected in
Bogotá – Colombia and participants were recruited through flyers
posted in different areas of the city (i.e., universities, schools, companies, factories, and libraries) and information that was posted on the
Internet and social networks. None of the current smokers were attempting to stop smoking at the time of the study. Table 1 summarizes
the basic demographic characteristics and smoking variables of the
sample.
The exclusion criteria were current medical or psychological treatment and visual problems without correction. The study was approved
by the University of San Buenaventura Review Board, and the subjects
provided written informed consent. After the study, all of the participants were given information on where to seek counseling to moderate
or quit smoking.
Table 1
Demographic characteristics and smoking variables in nonsmokers, weekly smokers, and daily smokers.
Age (years) (mean [SD])
Sex (% male)
Sex (% female)
CPD (mean [SD])
Age of smoking onset (mean [SD])
Nonsmokers (n = 35)
Weekly smokers (n = 35)
Daily smokers (n = 35)
χ2 or F
p
21.80 (3.54)
51.4
48.6
0 (0.00)
0 (0.00)
22.57 (5.95)
68.4
31.6
0.42 (0.26)
16.21 (2.41)
20.68 (2.35)
51.4
48.6
7.80 (4.90)
15.49 (2.26)
1.09
1.74
0.33
0.41
65.37
809.32
< 0.001
< 0.001
CPD, cigarettes per day; SD, standard deviation.
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C. Gantiva et al.
were T-transformed within subjects. A total of 8.09% of all of the trials
were excluded because of unstable baseline activity or outlier responses.
2.2. Stimuli and procedure
To test the effect of the size of GHWs on emotional and motivational
responses, we used three different categories of stimuli. The first category included cigarette packs without GHWs. The second category included cigarette packs with GHWs with the minimum size that is recommended by World Health Organization [WHO], 2005; (i.e., 30%
coverage of the cigarette pack). The third category included cigarette
packs with GHWs with double the minimum size (i.e., 60% coverage of
the cigarette pack). A total of 27 pictures were used in the study (nine
pictures for each category). The GHWs were presented without text. In
all cases, the cigarette brands used were the three most sold in Colombia (i.e., Marlboro, Mustang and Kool). All of the pictures were
presented in color. To avoid an habituation effect, the GHWs chosen for
the present study were nine images that are used in the European
Union, which have not been used in the country of the study population. The selected GHWs were the nine most aversive images according
to valence scores from the study by Muñoz et al. (2013) (GHW picture
codes 03 h, 04 h, 06 h, 10 h, 18 h, 19 h, 30 h, 31 h, and 36 h).
The pictures were presented for 6 s on a 19-in. flat-screen monitor
that was located approximately 60 cm from the subject. All of the pictures were presented only once in four counterbalanced orders with 27
trials each, with the constraint of not presenting pictures from the same
category consecutively. The intertrial interval (ITI) varied randomly
between 10 and 14 s. The startle probes consisted of 50 ms, 105 dB
white-noise bursts with an instantaneous rise time that were presented
through headphones with binaural sound 4–5.5 s after picture onset
(Blumenthal et al., 2005). The startle probes were presented randomly
in six of the trials in each category and during three ITIs. The presentation of the pictures and startle probes were programmed using EPrime 2.0 software (Psychology Software Tools, PA, USA).
2.5. Self-report measures
The Self-Assessment Manikin (SAM, Bradley & Lang, 1994), was
used to evaluate affect in response to the pictures. The SAM is a pictorial nonverbal measure of emotion that consists of three affective 9point scales: valence, arousal, and dominance. For the valence scale, the
SAM ranges from a smiling happy figure to a frowning unhappy figure.
For the arousal scale, the SAM ranges from a relaxed, sleepy figure with
eyes close to an excited, wide-eyed figure. For the dominance scale, the
SAM ranges from a very small figure that represents a feeling of being
controlled to a very large figure that represents being in control.
The Pictographic Assessment of Desire (PAD, Muñoz, Martínez,
Fernández-Santaella, Vila, & Cepeda-Benito, 2010), was used to assess
the strength of craving that was produced by the pictures. Similar to the
SAM, it consists of a scale of five humanoid figures that represent different degrees of craving or desire to consume a substance. Scores range
from 1 (low craving) to 9 (high craving).
2.6. Statistical analysis
Physiological and self-report measures were analyzed using a 3 × 3
repeated-measures analysis of variance (ANOVA), with Group (nonsmokers, weekly smokers and daily smokers) as the between-group
factor and Picture (cigarette pack without GHW, cigarette pack with
GHW that covered 30% of the pack, and cigarette pack with GHW that
covered 60% of the pack) as the repeated measure. When the assumption of sphericity was not met, Greenhouse-Geisser correction was
applied to the degrees of freedom in all cases. Post hoc analyses of the
mean values were performed using paired multiple comparisons with
Bonferroni correction. The level of significance was set at p < .05. All
of the statistical analyses were performed using Statistical Package for
Social Sciences (SPSS) 20.0 software.
2.3. Physiological measures
PowerLab 26 T equipment (ADInstruments, Australia) was used to
record skin conductance and electromyographic (EMG) activity. Skin
conductance was recorded from two dry, bright-plated bipolar electrodes that were placed on the intermediate phalanges of the 2nd and
4th digits on the nondominant hand. The signal was calibrated before
each session to detect activity in the range of 0–40 microSiemens (μS)
and recorded using an ADInstruments Model ML116 GSRAmp. Left
orbicularis and corrugator EMG activity was measured using two 4 mm
Ag/AgCl electrodes over each muscle (Fridlund & Cacioppo, 1986).
Electrode impedances were kept below 30 kΩ. Orbicularis EMG activity
was recorded using a 10–500 Hz frequency band filter that was rectified
and integrated with a time constant of 20 ms. Corrugator EMG activity
was recorded using a 10–1000 Hz frequency band filter that was rectified and integrated with a time constant of 500 ms. All of the signals
were acquired at a sampling rate of 1000 Hz.
3. Results
3.1. Skin conductance response (SCR)
The ANOVA of the SCR revealed significant main effects of Group
(F2,96 = 6.17, p = .003, ηp2 = 0.11) and Picture (F2,192 = 4.26, p = .01,
ηp2 = 0.04). Weekly smokers generally responded with a larger SCR
compared with nonsmokers (p = .004, Cohen's d = .76) and daily
smokers (p = .02, Cohen's d = .55). Only GHWs that covered 60% of
the pack generated significantly larger SCRs compared with cigarette
packs without GHWs (p = .03, Cohen's d = .20). As shown in Fig. 1A,
when the pictures were ordered by the size of the GHW, a linear relationship was observed, which was supported by a significant linear
trend (F1,96 = 6.38, p = .01, ηp2 = 0.06). No significant Group × Picture interaction was found (F < 1).
2.4. Data reduction
The SCR and corrugator muscle response were determined by subtracting activity in the 1 s before picture presentation from activity that
occurred at each 0.5 s during the first 4 s of the presentation of each
picture. To evaluate the SCR, the maximum change that occurred between 1 and 4 s after picture onset was scored, and the values were
square-root-transformed prior to analysis to normalize the data. To
estimate corrugator muscle reactivity, the average change that occurred
between 1 and 4 s after picture onset was scored.
Startle blink magnitude was defined as the first maximum increase
of EMG activity of the orbicularis oculi muscle within a time interval of
20–150 ms after startle probe onset. The mean EMG of the 25 ms
baseline that directly preceded the onset was subtracted to measure the
startle amplitude (Blumenthal et al., 2005). To correct for large individual variability in blink magnitude, eye-blink reflex magnitudes
3.2. Corrugator muscle activity
The ANOVA of corrugator muscle activity revealed a significant
main effect of Picture (F2,192 = 4.81, p = .01, ηp2 = 0.04). Only GHWs
that covered 60% of the pack generated greater corrugator muscle activity than cigarette packs without GHWs (p = .01, Cohen's d=.33).
When the pictures were ordered by the size of the GHW, a significant
linear trend was found (F1,96 = 8.10, p = .005, ηp2 = 0.08; Fig. 1B). No
main effect of Group was found (F < 1), with no Group × Picture
interaction (F < 1).
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C. Gantiva et al.
Fig. 1. Physiological responses (skin conductance response, corrugator muscle activity and startle reflex) to different size of GHWs. Note: * p < .05. GHW: Graphic
Health Warning. Bars indicate ± 1 SEM
3.3. Startle response
4. Discussion
The ANOVA of the startle reflex data revealed a significant main
effect of Picture (F2,192 = 8.61, p < .001, ηp2 = 0.09). Graphic health
warnings that covered 60% of the pack enhanced the startle response
compared with cigarette packs without GHWs (p < .001, Cohen's
d = .84). When the pictures were ordered by the size of the GHW, a
significant linear trend was found (F1,96 = 23.14, p < .001,
ηp2 = 0.22; Fig. 1C). No other significant main effect or interaction was
found (all ps > .07).
The objective of the present study was to evaluate the effect of the
size of GHWs on physiological responses that are indicative of arousal
and aversive motivation in nonsmokers, weekly smokers, and daily
smokers. We sought to determine whether the minimum size of GHWs
that is recommended by the WHO is sufficient to generate an emotional
response that favors avoidance of the cigarette pack. Our results
showed that GHWs that covered 30% of the pack failed to generate
greater arousal responses and greater aversive motivational responses
than cigarette packs without GHWs. In contrast, with a 60% coverage of
the pack, the arousal and aversive motivational responses increased, as
compared with cigarette packs without GHWs. Especially, the startle
reflex, which had a large effect size, suggesting a strong influence of the
GHW size on the activation of the defensive motivational system
(Bradley et al., 2001).
Overall, these results suggest that the minimum size of GHWs that is
recommended by the WHO (2005) is insufficient to generate an emotional response that leads to avoidance of the cigarette pack. The absence of significant differences between nonsmokers, weekly smokers,
and daily smokers suggests that the effect of the size of GHWs on
psychophysiological responses is similar in these groups.
Our results showed that GHWs that covered 30% of the package did
not significantly increase the aversive valence of the cigarette packs
(i.e., did not increase corrugator muscle activity or the startle reflex).
Similar results were recently reported using self-report measures
(Gantiva et al., 2016). However, when the size of the GHW was enlarged to 60% of the pack, significant increases in corrugator muscle
activity and the startle reflex were observed. This indicated activation
of the defensive motivational system (Bradley et al., 2001), and thus, a
greater probability of avoiding the cigarette pack. Additionally, significant linear trends in corrugator muscle activity and the startle reflex
were found, suggesting that the increase in size of the GHW progressively increased the aversive response, thus decreasing the attractiveness of the cigarette pack.
The effect of the size of the GHW on the SCR showed that GHWs that
covered 30% of the pack did not significantly increase the arousal response. Only GHWs that covered 60% of the pack generated a higher
SCR compared with cigarette packs without GHWs, indicating increases
in orientation and arousal responses (Bradley, 2009). These findings,
together with the results of corrugator muscle activity and the startle
response, suggest a greater probability of avoidance behavior toward
the cigarette pack. A significant linear trend was found for the SCR, in
which the increase in the size of the GHW progressively increased
arousal responses. Similar results were reported by Codispoti and De
3.4. Subjective ratings
Table 2 shows the means and standard deviations for valence,
arousal, dominance, and craving ratings for all groups. The ANOVA of
the valence dimension revealed no significant main effects or interaction (all ps > .06). The ANOVA of the arousal dimension revealed a
significant main effect of Group (F2,96 = 5.02, p = .009, ηp2 = 0.10).
Daily smokers evaluated the stimuli as more arousing compared with
nonsmokers (p = .006, Cohen's d = .76). The ANOVA of the dominance
dimension revealed a significant main effect of Group (F2,96 = 13.41,
p < .001, ηp2 = 0.23). Daily smokers had lower dominance scores
compared with nonsmokers and weekly smokers (both ps < .05, Cohen's d = 1.25 and .59 respectively). The ANOVA of the PAD craving
scores revealed a significant main effect of Group (F2,96 = 31.02,
p < .001, ηp2 = 0.41). Nonsmokers had lower craving scores compared
with weekly smokers and daily smokers (both ps < .001, Cohen's
d = 1.60 and 1.97 respectively).
Table 2
Valence, arousal, dominance, and craving ratings (mean [standard deviation]).
Valence
Arousal
Dominance
Craving
Cigarette packs
GHWs at 30%
GHWs at 60%
Cigarette packs
GHWs at 30%
GHWs at 60%
Cigarette packs
GHWs at 30%
GHWs at 60%
Cigarette packs
GHWs at 30%
GHWs at 60%
Nonsmokers
Weekly smokers
Daily smokers
3.48(1.57)
3.36(1.42)
3.31(1.48)
2.84(1.76)
2.75(1.44)
2.72(1.54)
8.13(1.11)
8.09(0.97)
8.12(1.10)
1.15(0.42)
1.21(0.42)
1.16(0.39)
4.12(1.44)
4.22(1.49)
4.05(1.57)
3.35(1.64)
3.29(1.57)
3.34(1.79)
7.46(1.32)
7.43(1.32)
7.47(1.28)
3.04(1.63)
3.23(1.74)
2.89(1.57)
3.98(0.97)
3.89(0.86)
3.89(0.89)
3.87(1.82)
3.90(1.72)
4.22(1.78)
6.62(1.38)
6.53(1.58)
6.57(1.46)
3.42(1.64)
3.56(1.64)
3.59(1.85)
Note: GHW: Graphic Health Warning.
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C. Gantiva et al.
Cesarei (2007), who found a higher SCR toward larger pictures compared with smaller pictures.
With regard to subjective measures, the results indicated that daily
smokers experienced greater subjective arousal, lower dominance, and
higher craving. These results can be explained by the fact that in all
categories of the presented images (i.e., cigarette packs without GHWs,
cigarette packs with 30% GHWs, and cigarette packs with 60% GHWs),
there were always tobacco-related cues (e.g., the complete cigarette
pack or part of the pack) that can generate a “wanting” response in
smokers, characterized by greater arousal perception, poor control
perception, and a greater desire to consume because of the incentive
salience of the tobacco-related cues (Berridge, 2009; Robinson &
Berridge, 1993). This hypothesis could be tested in a future study by
comparing the physiological and subjective responses to the same set of
images and to other stimuli (e.g., IAPS pictures).
The differences between physiological and subjective measures
have also been found in other specific populations (e.g., anxious subjects), suggesting that cognitive processes (e.g., expectations and beliefs) influence the subjective evaluation of stimuli that evoke emotional responses (Diemer, Lohkamp, Mühlberger, & Zwanzger, 2016;
Matias Jr & Turner, 1986). Additionally, autonomic responses and
subjective reports are differentially modulated by factors that affect
stimulus relevance (Codispoti & De Cesarei, 2007).
The present study has several limitations. First, only two sizes of
GHWs were evaluated. Future investigations should evaluate other
sizes. Nonetheless, the significant linear trends that were found in the
present study indicate that increasing the GHW size progressively increases arousal response and aversion of the pack. Second, only peripheral responses were recorded. Future investigations should also
study central responses (e.g., electroencephalography) to provide a
better understanding of the emotional processing of GHWs. Third, the
sample did not include ex-smokers, so it was not possible to evaluate
the ability of GHWs to prevent relapse.
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5. Conclusions
Overall, our results suggest that the minimum GHW size that is
recommended by the WHO (2005) (30% coverage of the cigarette pack)
is insufficient to significantly reduce the attractiveness of cigarette
packs and to generate an emotional response that favor avoidance of
the pack. Increasing the size of GHWs to 60% of the cigarette pack may
better prevent cigarette smoking and facilitate smoking cessation.
Funding
This work was supported by Colciencias under Grant (CT 0202018); and Universidad de San Buenaventura under Grant (CHS_12_10).
Colciencias and Universidad de San Buenaventura had no role in the
study design, collection, analysis or interpretation of the data, writing
the manuscript, or the decision to submit the paper for publication.
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