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Table 1 Participant and methodological characteristics of articles eligible for inclusion in this systematic review (n = 19)

From: A systematic review of the perceptions of adolescents on graphic health warnings and plain packaging of cigarettes

Year published and main author Location, participant numbers, and age range Gender distribution Participant smoking status Mode of study and interventions employed Data collection and outcomes reported
M% F% NS% EX% S%
2009 Hammond [35] UK
n = 806
11–17 years
51.6 48.4 72.6 27.4 An online survey displaying six pairs of cigarette packs (using two brands), with branded, plain white, and plain brown packaging used, all displaying the same GHW. Participants chose from each pair (or indicated ‘no difference’) which pack would have most tar delivery, smoothest taste, reduced health risks, highest attractiveness, and choice to smoke.
2009 Vardavas [26] Greece
n = 574
12–18 years
46.0 54.0 80.6 19.4 An in-school digital survey using computer-generated images, displaying pairs of seven existing text-only warnings with a comparative proposed GHWs on un-branded packaging. Participants rated warnings using 5-point Likert scales on perceived effectiveness in preventing smoking, depicting the impact of smoking on health, and perceived warning strength.
2010* Fong [27] China
n = 396
13–17 years
50.8 49.2 87.9 8.1 4.0 Digitally constructed warnings were presented in person as photographs to adult and adolescent residents of four Chinese cities. Five pairs of cigarette packaging (four pairs with text-only versus GHW) were displayed. Participants ranked and rated warnings using 5-point Likert scales on effectiveness in motivating smokers to quit, preventing youth smoking, informing the public on the harms of smoking, and showing government anti-tobacco initiative.
2010 Germain [42] Australia
n = 1087
14–17 years
49.4 50.6 60.4 21.9 39.7 An online survey, with each participant randomly viewing one of 15 packs, varying in brand presented (3 brands), degree of brand prominence, and size of GHW (3 × 5 design). Participants rated on 5-point Likert scales; five perceived pack attributes, five perceived smoker attributes, and seven perceived cigarette attributes.
2011 Hammond [36] USA
n = 826
18–19 years
100 60.9 15.0 39.1 An online survey with participants viewing eight packages grouped into four categories: female-oriented brand with descriptors, female-oriented brand without descriptors, plain, and non-female-oriented brand. Participants rated on 5-point Likert scales: brand appeal, brand taste, tar quantity, and health risks for each package. Participants also indicated on seven perceived attributes per pack (e.g. glamour, coolness, popularity) and their preferred pack.
2012a Hammond [28] Mexico
n = 528
16–18 years
50.0 50.0 51.1 48.9 Face to face survey with participants viewing warnings from 2 of 15 health-effect themes, each of which contained 1 text-only, and 4 to 6 pictorial warnings. Each theme included; graphic health warnings, lived experiences, symbolic representations, and testimonials. Participants rated 11 measures on 10-point Likert scales, including perceived message: credibility, personal relevance, and affective responses. Four of these 11 items related to perceived effectiveness, including motivating smokers to quit and preventing non-smokers from smoking.
2012b Hammond [37] UK
n = 947
16–19 years
100 68.9 31.1 An online survey with participants assigned to one of four categories, each containing 10 cigarette packages: female-oriented brand with descriptors, female-oriented brand without descriptors, plain, and non-female-oriented brand. Participants rated on 5-point Likert scales: brand appeal, brand taste, tar quantity, and health risks for each package. Participants also indicated on seven perceived attributes per pack (e.g. glamour, coolness, popularity) and their preferred pack.
2012 Moodie [38] UK
n = 658
10–17 years
47.3 52.7 90.9 9.1 An online survey with participants viewing several colours of plain cigarette packs with a text ‘Smoking Kills’ warning (white, red, green, light blue), and a brown plain pack of standard, sliding, and super-slim designs. Participants rated the four coloured packs on 5-point Likert scales their perceived taste and harm. The standard brown plain pack was rated on eight perception items (four pack and four smoker items), and preference compared to other designs.
2013 Ford [39] UK
n = 1025
11–16 years
51.5 48.5 100 In-home surveys with participants viewing four branded packs (standard, slim, novel opening mechanism, and striking colour) and one plain pack with the same text warning. Participants rated 11 items on 5-point semantic scales relating to package attractiveness, coolness, perceived harm, eye-catching, interest in smoking, and liking/disliking the pack.
2013a* Hammond [29] USA
n = 510
16–18 years
52.4 47.6 69.2 30.8 An online survey with participants randomly assigned to view two of nine sets of GHWs proposed by the FDA (6–7 warnings per set), with each GHW per set displaying the same text warning. Participants rated several warning aspects on 10-point scales, including increase in concerns of health risks, efficacy motivating smokers to quit and preventing youth from smoking, and overall warning effectiveness.
2013b Hammond [43] UK
n = 762
11–17 years
54.9 45.1 93.8 1.0 4.9 An online survey with participants viewing six pairs of packs, comparing a regular pack to white or brown plain packs with moderate-sized text or graphic warnings (40%), or large-sized (80%) graphic warnings (2 × 3 model). Participants selected from each pair (or indicated ‘no difference’) which pack would have most tar delivery, smoother taste, reduced health risks, highest attractiveness, would prompt to start smoking, and choice to smoke.
2013 Pepper [30] USA
n = 386
11–17 years
100 100 An online survey with participants randomly viewing one of four pack categories: addiction text-only warning, addiction text and image, lung cancer text-only warning, and lung cancer text and image (2 × 2 model). Participants rated 5-point scales the perceived effectiveness of their warning in discouraging them from smoking, and the perceived likelihood and severity of suffering from the described condition (addiction or lung cancer).
2015* Alaouie [31] Lebanon
n = 1412
13–18 years
42.9 57.1 90.4% ex-smoker or non-smoker 9.6 Face-to-face interviews across 28 schools and universities, with students presented with two of five GHW on plain white packs compared to a locally available text-only warning. Participants rated on 5-point Likert scales their perceived: message usefulness, noticeability, susceptibility, effectiveness, fear-arousal, self-efficacy in changing behaviour, intentions to not-smoke, and influencing family and close-contacts.
2015 Babineau [40] Ireland
n = 1378
16–17 years
55.7 43.7 78.6 4.2 17.2 In-school surveys for students across 27 schools. Pairs of packaging for three brands were presented. Packs were either branded or plain, with identical GHWs (lung damage). Participants chose one pack (or indicated ‘no difference’) from each pair based on pack attractiveness, perceived health risks, perceptions of popular smoker attributes, and pack preference.
2016 Adebiyi [32] Nigeria
n = 544
13–17 years
44.7 55.3 98.3 1.7 In-school surveys in two schools in a single community, with participants viewing four GHWs: smoking harming children, and causing airway cancer, stroke, and impotence. Participants indicated if each warning evoked: fear; shock, anxiety, or indifference. They also utilised a 3-point Likert scale on the effectiveness of each GHWs in preventing smoking initiation.
2016 Andrews [44] USA, Spain, France
n = 1066
13–18 years
50.0 50.0 100 An online survey with participants viewing one of eight packs (four plain and four branded) with varying levels of graphicness of GHWs, depicting the risks of smoking causing mouth cancer (2 × 4 model). Participants rated using 6- and 7-point scales in response to the pack their: cigarette cravings, evoked fear (4 items), pack feelings (3 items e.g. embarrassed), and thoughts of quitting (4 items).
2016 Mutti [41] Mexico
n = 359
16–18 years
48.5 51.5 42.9 47.1 A face-to-face electronic survey with participants viewing a set of 12 gender-specific packs that were either fully branded or plain with brand name and descriptors. Participants rated (yes/no/no difference) each pack on appeal, perceived taste, and perceived harm, with perceived smoker traits also rated (e.g. femininity, glamour, coolness, and popularity).
2016 Netemeyer [33] USA
n = 349
13–18 years
53.0 47.0 58.5 41.5 An online survey with participants randomly viewing one of nine cigarette packages containing a combined text and GHW. Participants rated fear, guilt, and disgust evoked; perceived graphicness of the warning; and personal and perceived peer consideration of smoking after viewing.
2017 Reid [34] India, Bangladesh, China, Korea
n = 2322
16–18 years
50.2 49.8 77.3 22.7^ Online survey in Korea and China, and computer-assisted interviews in India and Bangladesh. Participants viewed 2 of 15 sets of cigarette packaging warning. Each set included 5–6 warnings on the same consequence of smoking, and included one text-only warning, GHW, lived experience, and testimonial. Participants were assessed on their perceptions of the potential health effects of smoking for all 15 sets of warning after viewing their randomly assigned two sets. Participants either ‘agreed’, ‘disagreed’, or responded ‘do not know’ to each health consequence listed.
  1. GHW Graphic health warning Alaouie et al. [31]: smoking prevalence higher in males (18.2% vs. 3.4%)—statistics do not include narghile smoking
  2. *Adult smokers participated in this study, though their results have been omitted in this review
  3. ^There were significant differences in smoking status between different countries (see Table 2)