Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses

Background: The Extended Parallel Process Model (EPPM) responses that emerge from spontaneous reactions to cigarette warning labels remain understudied. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions. Methods: U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n = 1838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions. Results: Participants’ responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories. Conclusions: The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial warning labels.