Perceptions of the Proposed Food and Drug Administration Graphic Cigarette Warnings Among Adults Who Smoke on a Nondaily or Daily Basis: A Within-Subjects Experiment

<h2>Abstract</h2><h3>Background</h3> People who smoke nondaily represent nearly one third of U.S. adults who smoke and experience significant smoking-related morbidity and mortality, yet are rarely considered when evaluating the efficacy of graphic cigarette warnings. <h3>Method</h3> In October 2019, U.S. adults who smoked nondaily (n=59) and daily (n=183) evaluated 13 FDA-proposed graphic warnings and 13 equivalent text-only warnings on the extent to which they elicited understanding, perceived new knowledge, worry about smoking, discouragement to smoke, and were believable. Repeated measures ANOVA and planned comparisons tested for between-subjects (smoking status) and within-subjects (warning type) effects. The strength of within subjects effects were characterized using Cohen's <i>d_p</i> and Common Language Effect Size. Finally, repeated measures ANCOVAs evaluated whether demographic characteristics (e.g., race/ethnicity) that differed between adults smoking nondaily and daily were associated with within-subject evaluations of graphic vs. text-only warnings. <h3>Results</h3> Adults who smoked nondaily (vs. daily) were younger (<i>p</i><.001), more educated (<i>p</i><.001), and less likely to be non-Hispanic White (<i>p</i>=.04), female (<i>p</i>=.04), or to intend to quit within six months (<i>p</i><.001). Adults smoking nondaily (vs. daily) rated graphic warnings as eliciting more discouragement to smoke (<i>p</i>=.045). Graphic (vs. text) warning evaluations were stronger for all outcomes in both groups (<i>p</i><.001). The effect sizes for graphic warnings were substantially larger among adults smoking nondaily for discouragement and believability (<i>d_p</i> difference of >.10). Race/ethnicity moderated evaluations of discouragement (<i>p</i>=.03) and believability (<i>p</i>=.01) among adults smoking nondaily and daily. <h3>Conclusion</h3> The capacity of graphic warnings to elicit responses associated with motivation to quit smoking may be particularly robust for adults smoking nondaily. That graphic warnings discourage smoking is promising for this underserved group of people who smoke.