Avoidance of tobacco health warnings? An eye-tracking approach

Carlos Sillero-Rejon, Ute Leonards, Marcus R Munafò , Olivia M Maynard*, et al.

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

12 Citations (Scopus)
133 Downloads (Pure)


Aims: Across three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings.
Design: Study 1: smoking status × warning immediacy (short-term vs. long-term health consequences) × warning location (top vs. bottom of pack). Study 2: smoking status × warning framing (gain-framed vs. loss-framed) × warning format (text-only vs. pictorial). Study 3: smoking status × warning severity (highly severe vs. moderately severe consequences of smoking).
Setting: University of Bristol, UK, eye-tracking laboratory.

Participants Study 1: non-smokers (n=25), weekly smokers (n=25), and daily smokers (n=25). Study 2: non-smokers (n=37), smokers contemplating quitting (n=37) and smokers not contemplating quitting (n=43). Study 3: non-smokers (n=27), weekly smokers (n=26) and daily smokers (n=26).

Measurements: For all studies: visual attention, measured as the ratio of the number of fixations to the warning vs the branding, self-reported predicted avoidance of and reactance to warnings and for Study 3, effect of warning on quitting motivation.

Findings: Study 1: Greater self-reported avoidance (Mean Difference (MD)=1.14;95%CI=0.94,1.35,p<0.001,ηp2 =0.64) and visual attention (MD=0.89,95%CI=0.09,1.68,p=0.03,ηp2 =0.06) to long-term warnings, but not for reactance (MD=0.14,95%CI=-0.04,0.32,p=0.12,ηp2 =0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD=1.8;95%CI=0.33,3.26,p=0.02,ηp2 =0.08). Study 2: Higher self-reported avoidance of (MD=0.70;95%CI=0.59,0.80,p<0.001,ηp2 =0.61) and reactance to (MD=0.37;95%CI=0.27,0.47,p<0.001,ηp2 =0.34) loss-framed warnings but little evidence of a difference for visual attention (MD=0.52;95%CI=-0.54,1.58,p=0.30,ηp2 =0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all ps<0.001,ηp2 >0.25). Study 3: Greater self-reported avoidance of (MD=0.37;95%CI=0.25,0.48,p<0.001,ηp2 =0.33) and reactance to (MD=0.14;95%CI=0.05,0.23, p=0.003,ηp2 =0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD=-0.55;95%CI=-1.5,0.41,p=0.24,ηp2 =0.02).

Conclusions: Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.
Original languageEnglish
Number of pages13
Early online date7 Jun 2020
Publication statusE-pub ahead of print - 7 Jun 2020

Structured keywords

  • Physical and Mental Health
  • Tobacco and Alcohol


  • tobacco health warnings
  • eye-tracking
  • attention
  • avoidance
  • reactance
  • message framing


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