The association between new graphic health warning labels on tobacco products and attitudes toward smoking among south Korean adolescents: a national cross-sectional study

BACKGROUND: Graphic health warning labels (GHWLs) on tobacco products are more effective than text warnings for communicating the risk of smoking. The implementation of GHWLs can prevent adolescents from initiating smoking. Therefore, this study examined the association between GHWLs newly implemented on December 23, 2016, in South Korea and attitudes toward smoking among adolescents. METHODS: This post-implementation cross-sectional analysis examined the responses of 62,276 students (31,624 boys and 30,652 girls) who participated in the 2017 Web-based Korean Youth Risk Behavior Survey, which was completed anonymously as a self-administered questionnaire by middle and high school students. Multinomial logistic regression was applied to explore the attitudes toward smoking among the youth (13–18 years old) who have been exposed to GHWLs in order to identify relationship of exposure to the GHWLs with smoking initiation and awareness of the danger of smoking. RESULTS: Six months after implementation, 69.4% of adolescents reported having been exposed to GHWLs in the previous 30 days. Among those exposed to GHWLs both boys and girls in grade 7 were significantly more likely than grade 12 high school students to decide not to start smoking (boys: AOR = 3.96, 95% CI 3.31–4.75, p < 0.001; girls: AOR = 2.76, 95% CI 2.32–3.30, p < 0.001) and to think that smoking was dangerous to their health (boys: AOR = 3.01, 95% CI 2.52–3.58, p < 0.001; girls: AOR = 2.42, 95% CI 2.03–3.88, p < 0.001) after seeing GHWLs. These associations were greater for adolescents who had experienced smoking-prevention education or had been exposed to anti-tobacco advertisements. However, those who smoked, used e-cigarettes, or experienced secondhand smoking were significantly less likely to decide not to smoke and to view smoking as dangerous. CONCLUSIONS: To maintain the perception of the harm of tobacco from childhood through adolescence, the government should implement both comprehensive tobacco controls, including smoking-prevention education in schools, and measures to encourage a smoke-free environment in homes.