IJERPH, Vol. 14, Pages 98: The Association between Warning Label Requirements and Cigarette Smoking Prevalence by Education-Findings from the Global Adult Tobacco Survey (GATS) (International Journal of Environmental Research and Public Health)

Introduction: The Guidelines for the implementation of Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) require that cigarette health warning labels should include pictures and take up 50% or more of the principal display area. This study examined how the association between large pictorial warnings, those covering >=50% of the front and back of the package, and the prevalence of cigarette smoking varies by educational attainment. Methods: We pooled individual-level tobacco use data from the Global Adult Tobacco Survey (GATS) in 18 countries between 2008 and 2013 and linked them with warning label requirements during the same period from the MPOWER database and reports regarding warnings. The respondents` self-reported exposure to warnings was examined according to education. Logistic regressions were further employed to analyze education-specific associations between large pictorial warnings and smoking prevalence, and whether such association differed by education was examined using an interaction test. Results: At the time of the survey, eight out of 18 countries had imposed graphic warning labels that covered >=50% of the package. These warnings were associated with a 10.0% (OR = 0.89; 95% CI: 0.81, 0.97; p