Tobacco package health warnings about product manipulations: an experimental study among Australian adults who smoke

The tobacco industry manipulates cigarettes to provide sensory cues that mislead people who smoke. We assessed the effectiveness of health warnings (HWs) focussed on the impact of misleading product attributes, including filter ventilation, menthol, and roll-your-own tobacco, which were called Product Attribute HWs. Australian adults who smoke (n = 2544) were randomly assigned to view: control medication warnings; new Standard HWs with smoking harm images; Product Attribute HWs; or Product Attribute HWs plus a video. At baseline, participants were exposed to seven condition-specific warnings (+ video for those in the Product Attribute HWs + Video condition), then they were potentially re-exposed to one warning daily for 7 days (+ up to six video viewings). Participants (n = 1414) were followed-up at 8 days. Compared to controls, exposure to Product Attribute HWs elicited: greater increases in concern when inhaling smoke with misleading favourable (e.g. smooth) and unfavourable (e.g. harsh) sensory cues; greater knowledge of industry manipulation; greater self-centric and industry-centric negative emotions; higher product-specific smoking dissonance; and a higher likelihood of past-week rumination about HWs. Compared to Standard HWs, Product Attribute HWs elicited greater knowledge of product manipulation and industry-centric negative emotions, but similar self-centric negative emotions and past-week rumination about warnings. Only the Product Attribute HWs + Video condition resulted in greater discussion and online information-seeking about warnings. Product Attribute HWs that challenge long-standing myths fostered by tobacco companies yield many similar outcomes to Standard HWs but also provide unique beneficial outcomes. Nations should consider including Product Attribute HWs in their suites of tobacco HWs.