The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages

BACKGROUND: Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants’ intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices. METHODS: A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data. RESULTS: After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01–1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14–1.69) and 1.29 (95% CI 1.04–1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample. CONCLUSIONS: Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers’ intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.