U.S. smokers have had nearly three decades to get used to the small health warnings on the side of their cigarette packages. But they may be in for a shock in the future. In June, the U.S. Food and Drug Administration approved nine new cigarette warning labels, and the big, bold new messages don't pull any punches. The warnings cover half the package and feature pictures of smokers' ravaged bodies: a diseased lung, a tracheotomy hole and a corpse with its chest sewn up.

Graphic cigarette warning labelCigarette makers have challenged the legality of the new warnings, and in November won the first round of litigation, when a U.S. District Court judge blocked the new labels. But around the world, the type of subtle labels that U.S. cigarette packs now display are on their way out. As researchers have continued to uncover more information about the harms of smoking and of secondhand smoke, governments have been moving to require larger, more graphic and scarier labels.

Canada was the first country to introduce large graphic warnings in 2001. In 2003, the World Health Organization passed its Framework Convention on Tobacco Control, which, among other measures, urged countries to mandate warnings that covered at least 30 percent to 50 percent of packages. Since then, Australia, Brazil, Thailand and dozens of other countries have switched to large graphic warnings.

Now, psychologists and other researchers are plumbing a decade's worth of data to try to understand what effect these new labels have had. They're finding evidence that the graphic labels do grab smokers' attention and can change self-reported attitudes toward smoking — including upping smokers' desire to quit.

Geoffrey Fong, PhD, director of the health psychology lab at the University of Waterloo in Canada, heads the International Tobacco Control Policy Evaluation Project, a decade-long study that has followed smokers in more than 20 countries to track the effects of graphic warning labels and other anti-smoking efforts.

"We have many natural experiments confirming that in the real world, warning labels work," he says.

Fong and his colleagues survey thousands of adult smokers in each country every year. They ask smokers how often they've noticed the warnings and how the warnings have affected their thoughts and behaviors. The survey also measures smokers' knowledge of the risks of smoking, such as whether they know that smoking can cause stroke.

In every country, the results of the ITC survey have suggested that the new warning labels are more effective than the old ones, Fong says. When Thailand moved from text-only to large, graphic warnings in 2006, the number of Thai smokers who said that warning labels made them think a lot about the health risks of smoking increased by 55 percent, and the number who said that labels made them a lot more likely to quit increased by 41 percent. Nearby Malaysia, which kept its small, text-only labels, saw no such attitude changes that year.

"The experiences of many countries — including Canada, Mauritius, Thailand, Mexico, Uruguay — have shown significant increases in many indicators of warning label impact," Fong says. "There are higher levels of noticing; much higher reports that the warning labels make you think about the health risks of smoking; a greater likelihood of considering quitting; and among people who have quit, a greater attribution of graphic warning labels as being part of that."

One impact measure that's missing from the ITC study, however, is smoking prevalence. The survey measures only attitudes, not whether people actually quit smoking.

That's because many factors can influence smoking rates, making it impossible to isolate the effect of graphic warning labels or other individual anti-smoking efforts, says David Hammond, PhD, a psychologist in the school of public health at the University of Waterloo and one of Fong's collaborators on the ITC study. At the same time that a country introduces new labels, for example, it might also introduce a new tax that increases the price of cigarettes, or it might ban cigarettes in restaurants, bars and other public places. Further complicating matters, those taxes and bans can happen on the local level, too.

Smoking prevalence "is like the economy — it's hard to pin it to one factor," Hammond says.

But he and Fong say the measures in their survey are backed up by psychological models of health behavior, and the attitude changes that the survey measures are correlated with actual behavior changes — like quitting smoking.

In a 2003 study of more than 600 Canadian smokers, for example, Hammond and Fong found that smokers who said they had read, thought about and discussed Canada's then-recently implemented graphic warning labels were significantly more likely to have tried to quit three months later. And government reports from both the United Kingdom and Brazil found that calls to national cigarette-quitting helplines increased significantly after those countries introduced graphic warning labels.

An avoidance effect

But not all researchers are convinced that the new warnings are a good idea. The graphic labels could have unintended consequences, says Rob Ruiter, PhD, a psychology professor at Maastricht University in the Netherlands. Although smokers may say that the warnings encourage them to quit, Ruiter has found that scary images may make smokers react defensively, quickly turning their attention away from the warnings and discounting the warning message.

In one study, published in Health Psychology in 2009, he showed 30 cigarette-related images to 15 smokers and 15 nonsmokers. Half of the images were scary, such as a diseased lung, and half were not, such as a picture of a healthy-looking person smoking. Using EEG, Ruiter found that smokers had less activity in an attention-related area of the brain when they switched from looking at the scary images to looking at different, target, images than when they switched from the neutral images to target images. That, he says, suggests that it was easier for them to pull their attention away from a scary image because they had already "disengaged" from it.

Such lab results, Ruiter says, suggest that smokers' subconscious defensive reactions may mean that they ignore the scary warnings, making the warnings less effective than policymakers believe they are.

Other researchers have found similar effects using self-report measures. In one British study, published in Health Psychology in 2007, University of Sheffield psychologist Peter Harris, PhD, showed both smokers and nonsmokers graphic cigarette warning images and asked them to rate how threatening they found the pictures, and how personally relevant. The smokers found the pictures no more personally relevant than the nonsmokers did, and actually found them less threatening.

"That seems ludicrous," says Harris. "But it suggests the smokers were being defensive."

Ruiter believes that there are more effective ways to combat smoking than scary warning messages.

"Why use fear when there are much more effective tools?" he says. "Price increases, public bans [on smoking in public places] … are much more effective than telling people how bad smoking is. People already know it's bad."

Fong and Hammond, however, say that Ruiter's objections miss several points. First, a lab-based study like the one described above looks only at the effect of a single viewing of a scary image. But a pack-a-day smoker would view warning labels thousands of times each year.

"If you're just dealing with single exposures, you don't have the sense of the richness of the experience," Fong says. "If you do a single experiment, you're looking at a different thing than the way these are presented in the real world."

In addition, Hammond says, the ITC survey does suggest that many people consciously try to avoid the graphic warning labels — about 30 percent of smokers say they try to cover the warnings up. But, Hammond says, when they followed up with those smokers, the people who tried to avoid the warnings were no less likely than those who didn't to say they'd thought about the warnings later.

"It's a bit like the classic pink elephant," Hammond says. "The more you try not to think about it, the harder it is."

Finally, Fong points out that increasing the size of cigarette warning labels has anti-smoking benefits beyond the packages' messages. In many countries, cigarette advertising is limited by law, so packaging is an important way that cigarette makers can market their product and build their brand. When warning labels take up 50 percent of a package's real estate — and draws attention from whatever else is on it — that marketing opportunity is diminished.

"The graphic warning labels interrupt the message that the industry is trying to convey," Fong says.

And the tobacco industry, at least, seems to be convinced that the new warning labels will be effective. In November, four U.S. tobacco companies won a lawsuit claiming that the new FDA-required labels violate their right to free speech. The Justice Department has not yet said whether it will appeal the ruling.