Public Release: 

Graphic anti-smoking posters may encourage some teens to begin smoking cigarettes

Counterintuitive findings question policy promoted by some advocates

RAND Corporation

Exposing teens to graphic anti-smoking posters may actually increase the risk that some start smoking, according to a new RAND Corporation study.

Conducted in a one-of-a-kind laboratory that replicates a convenience store, the study found that some teens who viewed posters depicting gruesome displays of smoking-caused diseases actually reported being more susceptible to cigarette smoking after viewing the displays during a shopping trip.

The negative effects were found among teens who, before viewing the posters, reported being at some risk for smoking. The graphic posters did not appear to have any effect on teens who were committed to never smoking.

"Our findings are counter intuitive and suggest that some anti-smoking strategies may actually go too far," said William Shadel, lead author of the study and a senior behavioral scientist at RAND, a nonprofit research organization.

The study is published online by the journal Nicotine & Tobacco Research.

Most of the tobacco industry's advertising spending is focused on point-of-sale retail locations such as convenience stores. These outlets are awash in posters for tobacco products, signs for price promotions and the tobacco power wall -- the display of cigarettes and other tobacco products that is prominent behind the checkout counter.

Studies indicate that most adolescents visit locations that sell tobacco on a near weekly basis, placing them at significant risk for repeated exposure to tobacco advertising. Numerous studies have linked such exposures to more-positive attitudes toward smoking among adolescents.

In response, some jurisdictions have proposed that graphic cigarette warning posters be displayed alongside the tobacco power wall and near the cash register. New York City mandated such warnings in 2009, but courts voided the regulation after lawsuits initiated by the tobacco industry.

For the RAND study, researchers had teens visit a replica of a convenience store to buy a few items. With about half of the teens, the checkout counter or the wall behind the cash register displayed a prominent poster showing a photo of a diseased mouth and the words "WARNING: Cigarettes cause cancer."

The poster used was drawn from among nine that the U.S. Food and Drug Administration had intended to put on cigarette packages and was the one had been rated as the most effective image by adolescents in previous research.

The 441 adolescents aged 11 to 17 who participated in the RAND experiment were surveyed about their attitudes toward cigarette smoking and asked about other items both before and after shopping in the replica convenience store. About 5 percent of the participants reported prior cigarette smoking and about 20 percent were considered at-risk for future cigarette smoking before visiting the convenience store.

Researchers say their analysis found that rather than disrupting the positive point-of-sale advertising in the convenience store, the graphic anti-smoking poster seemed to further heighten the smoking susceptibility of adolescents already considered at-risk for future tobacco use.

"It is possible that at-risk adolescents responded to the graphic warning posters in a defensive manner, causing them to discount or downplay the health risks portrayed in the poster," Shadel said. "It may also be possible that the graphic posters caused adolescents to divert their attention to the tobacco power wall, where they were exposed to pro-tobacco messages."

Researcher say that a shortcoming of their study is that they tested only one anti-smoking poster with the adolescents and they did not experiment with a variety of poster sizes or a greater variety of store placement.

"Our findings do suggest that policymakers should be careful when considering graphic warning posters as part of anti-tobacco education in retail environments," Shadel said. "This type of action either needs additional research or potentially should be abandoned in favor of better-demonstrated anti-smoking efforts."

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Support for the study was provided by the National Cancer Institute and the FDA Center for Tobacco Products. Other authors of the study are Steven C. Martino, Claude Setodji, Michael Dunbar, Daniela Kusuke, Serafina Lanna and Amanda Meyer.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.

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