Health warning messages on cigarette packs: how young smokers process it


Keywords: elaboration likelihood model, health warning messages, smoking, processing route


Background: One of the major smoking prevention strategies has been to educate the public and increase people’s awareness, using health warning messages. However, many young people continue smoking without paying attention to health risk messages on cigarette packets in Iran. Hence, this study was conducted to examine the processing route of anti-smoking messages and influencing cognitive factors by using the Elaboration Likelihood Model.

Study design: A case-control study.

Methods: The non-probability sample for the cross-sectional study consisted of 387 tobacco smokers in the age range of 18 to 30 years old. This study was conducted between July and November of 2018 in Tabriz, Iran. A researcher-designed questionnaire was used for the purpose of data collection. No causal inferences were drawn due to the non-experimental nature of the study.

Results: It was found that tobacco smokers often processed the health warning messages through the central route. Perceived severity, smoking abstinence self-efficacy, and psychological dependence were predictors of message processing through the central route. The results supported the conceptual model of cognitional predictors of the processing route.

Conclusions: To design and execute effective health warning messages to quit smoking, it is recommended to consider cognitive factors as a means to enhance critical thinking about the content of the health warning message.


1. Petrescu D, Vasiljevic M, Pepper J, Ribisl K, Marteau T. What is the impact of e-cigarette adverts on children’s perceptions of tobacco smoking? A randomised control trial. Tob Control. 2016; 23:S196-S.
2. Hammond D. Health warning messages on tobacco products: a review. Tob Control. 2011; 20:327-37.
3. Morgan JC, Byron MJ, Baig SA, Stepanov I, Brewer NT. How people think about the chemicals in cigarette smoke: a systematic review. J Behav Med. 2017; 40:553-64.
4. Oncken C, McKee S, Krishnan-Sarin S, O'Malley S, Mazure CM. Knowledge and perceived risk of smoking-related conditions: a survey of cigarette smokers. Preve Med. 2005; 40:779-84.
5. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control. 2016; 25:341-54.
6. Shanahan P, Elliott D. Evaluation of the effectiveness of the graphic health warnings on tobacco product packaging 2008. Canberra: Australian Government Department of Health and Ageing. 2009.
7. Mutti-Packer S, Collyer B, Hodgins DC. Perceptions of plain packaging and health warning labels for cannabis among young adults: findings from an experimental study. BMC Public Health. 2018; 18:1361.
8. Petty RE, Kasmer JA, Haugtvedt CP, Cacioppo JT. Source and message factors in persuasion: A reply to Stiff's critique of the Elaboration Likelihood Model. 1987.
9. Petty RE, Cacioppo JT, Schumann D. Central and peripheral routes to advertising effectiveness: The moderating role of involvement. J Consum Res. 1983; 10:135-46.
10. Petty RE, Cacioppo JT. Communication and persuasion: Central and peripheral routes to attitude change: Springer Science & Business Media; 2012.
11. Petty RE, Cacioppo JT. The elaboration likelihood model of persuasion. Adv Experiment Soc Psycho. 1986; 19:123-205.
12. Trumbo CW. Information Processing and Risk Perception: An Adaptation of the Heuristic-Systematic Model. J Communication. 2002; 52:367-82.
13. Dinoff BL, Kowalski RM. Reducing AIDS risk behavior: The combined efficacy of protection motivation theory and the elaboration likelihood model. J Soc Clin Psycho. 1999; 18:223-39.
14. Angst CM, Agarwal R. Adoption of Electronic Health Records in the Presence of Privacy Concerns: The Elaboration Likelihood Model and Individual Persuasion. MIS Q. 2009; 33:339–70.
15. Zhou T. Understanding users’ initial trust in mobile banking: An elaboration likelihood perspective. Comput Hum Behav. 2012; 28:1518-25.
16. Yoo CW, Goo J, Huang CD, Nam K, Woo M. Improving travel decision support satisfaction with smart tourism technologies: A framework of tourist elaboration likelihood and self-efficacy. Technol Forcast Soc. 2017; 123:330-41.
17. Kosmidou K, Zopounidis C. The determinants of banks' profits in Greece during the period of EU financial integration. Managerial Finance. 2008; 34:146-59.
18. Te'eni-Harari T, Lampert SI, Lehman-Wilzig S. Information processing of advertising among young people: The elaboration likelihood model as applied to youth. J Adverte Res. 2007; 47:326-40.
19. Lins de Holanda Coelho G, H. P. Hanel P, J. Wolf L. The Very Efficient Assessment of Need for Cognition: Developing a Six-Item Version. Assessment. 2018:1073191118793208.
20. Cacioppo JT, Petty RE. The need for cognition. J Personal Socio Psycho. 1982; 42:116-31.
21. Harris JK, Karamehic-Muratovic A, Herbers SH, Moreland-Russell S, Cheskin R, Lindberg KA. Perceptions of personal risk about smoking and health among Bosnian refugees living in the United States. J Immigr Minor Health. 2012; 14:413-9.
22. Hoyle RH, Stephenson MT, Palmgreen P, Lorch EP, Donohew RL. Reliability and validity of a brief measure of sensation seeking. Personality and Individual Differences. 2002; 32:401-14.
23. DiFranza JR, Wellman RJ, Ursprung W, Sabiston C. The Autonomy Over Smoking Scale. Psycho Addict Behav. 2009; 23:656.
24. Spek V, Lemmens F, Chatrou M, van Kempen S, Pouwer F, Pop V. Development of a smoking abstinence self-efficacy questionnaire. Int J Behav Med. 2013; 20:444-9.
25. Witte K, Meyer G, Martell D. Effective health risk messages: A step-by-step guide. Thousand Oaks: CA: Sage; 2001.
26. Weston R, Gore Jr PA. A brief guide to structural equation modeling. The counseling psychologist. 2006; 34:719-51.
27. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice 4th Edition. Jossey-Bass publisher; 2008.
28. Munoz Y, Chebat J-C, Borges A. Graphic gambling warnings: How they affect emotions, cognitive responses and attitude change. J Gamb Stud. 2013; 29:507-24.
29. Kopp M, Wolf M, Ruedl G, Burtscher M. Differences in Sensation Seeking Between Alpine Skiers, Snowboarders and Ski Tourers. J Sports Sci Med. 2016; 15:11-6.
30. Guillaumin C, Urban T. The fight against smoking. The need to consider behavioral dependence. Revue de pneumologie clinique. 2017; 73:294-8.
31. Zuckerman M. Sensation seeking and risky behavior: American Psychological Association Washington, DC; 2007.
32. Steinberg L, Albert D, Cauffman E, Banich M, Graham S, Woolard J. Age differences in sensation seeking and impulsivity as indexed by behavior and self-report: evidence for a dual systems model. Dev Psycho. 2008; 44:1764.
33. Blanton H, Snyder LB, Strauts E, Larson JG. Effect of graphic cigarette warnings on smoking intentions in young adults. PloS one. 2014; 9:e96315.
34. Koval JJ, Aubut J-AL, Pederson LL, O’Hegarty M, Chan SS. The potential effectiveness of warning labels on cigarette packages. Can J Public Health. 2005; 96:353-6.
35. Omar M, Lajis, R., Foong, K., Sirirassamee, B., Sethaput, C., Borland, R., Fong, G.T., Hammond, D., Thompson, M.E., Driezen, P. & Elton-Marshall. Proceedings of the 13th World Conference on Tobacco OR Health, Washington DC, USA,. 2006.
36. Eagly AH, Chaiken S. The psychology of attitudes. Fort Worth TX: Harcourt Brace Jovanovich.; 1993.