Representation, Exemplification, and Risk: Resonance of Tobacco Graphic Health Warnings Across Diverse Populations

ABSTRACT

As countries implement Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control, graphic warning labels that use images of people and their body parts to illustrate the consequences of smoking are being added to cigarette packs. According to exemplification theory, these case examples—exemplars—can shape perceptions about risk and may resonate differently among demographic subpopulations. Drawing on data from eight focus groups (N = 63) with smokers and nonsmokers from vulnerable populations, this qualitative study explores whether people considered exemplars in their reactions to and evaluations of U.S. graphic health warning labels initially proposed by the Food and Drug Administration. Participants made reference to prior and concurrent mass media messages and exemplars during the focus groups and used demographic cues in making sense of the images on the warning labels. Participants were particularly sensitive to age of the exemplars and how it might affect label effectiveness and beliefs about smoking. Race and socioeconomic status also were salient for some participants. We recommend that exemplars and exemplification be considered when selecting and evaluating graphic health warnings for tobacco labels and associated media campaigns.

Acknowledgments

The authors thank Sara Minsky, Shoba Ramanadhan, Rachel McCloud, and Carmenza Bruff from the Center for Community-Based Research, and our community partners: Vilma Lora, Mayor’s Health Task Force, Lawrence, MA; Clara Savage, Common Pathways, Worcester, MA; and David Aronstein of Boston Alliance for Community Health. Thanks also to Joshua Gagne for his assistance with data collection and analysis, and to the two anonymous reviewers for their helpful comments.

Funding

This article was supported by the Yerby postdoctoral fellowship at the Harvard T.H. Chan School of Public Health (C.A.B.), the National Cancer Institute-funded Harvard Education Program in Cancer Prevention (5 R25-CA057711) (R.H.N.), and National Cancer Institute grant 3P50-CA148596-03S1 (K.V., PI). R.H.N. also acknowledges support from the Building Interdisciplinary Research Careers in Women’s Health Grant (2 K12-HD055887) from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development, the Office of Research on Women’s Health, and the National Institute on Aging, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Notes

¹ FDA initially proposed using a set of nine graphic warning labels, but the labels were challenged in court. Mixed court decisions have resulted in the agency deciding not to pursue the labels that they initially proposed, but indicating that they would move forward to implement their regulatory charge regarding graphic health warning labels (Late, 2013). Although the warning labels we sought reactions to in these focus groups are no longer likely to be the specific ones that are released, we believe the reactions and comments regarding exemplification nevertheless have implications for tobacco graphic warnings more generally and accompanying campaigns.

² In the identifier “B1,” the letter refers to the first letter of the name of the city where the focus group was held (i.e., Boston). The number identifies which focus group it was in that location (i.e., the first). See Table 1 for a full list of the focus groups, their characteristics, and their abbreviated identifiers.

³ Portions of CDC’s campaign “Tips From Former Smokers” preceded and overlapped our period of data collection.

⁴ Family Guy is a Fox Broadcasting Company television show.

Additional information

Funding

This article was supported by the Yerby postdoctoral fellowship at the Harvard T.H. Chan School of Public Health (C.A.B.), the National Cancer Institute-funded Harvard Education Program in Cancer Prevention (5 R25-CA057711) (R.H.N.), and National Cancer Institute grant 3P50-CA148596-03S1 (K.V., PI). R.H.N. also acknowledges support from the Building Interdisciplinary Research Careers in Women’s Health Grant (2 K12-HD055887) from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development, the Office of Research on Women’s Health, and the National Institute on Aging, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.