Introduction and objectives Graphic Health Warning Labels (GHWL) assist in primary and secondary smoking prevention. A lack of evidence exists regarding their desensitisation with increased exposure. Investigating knowledge and attitudes around GHWL may allow better implementation of future public health policies. Singapore introduced GHWL in 2004, five years before they were introduced in the UK; this study aims to investigate any potential desensitisation effect by direct comparison.
Methods Data were collected from 266 smokers and non-smokers, 163 from London (54.6% smokers, 54.0% male, mean age 52.4 (17.8)) and 103 from Singapore (47.6% smokers, 77.7% male, mean age 57.7 (14.5)) between 2011 and 2013. A structured interview with fifty items, showing ten different GHWL, recorded demographics, smoking history, plans to quit and knowledge about the health-related consequences of smoking, as well as the emotional response, processing and impact of GHWL on behaviour. Participants further ranked hypothetical conditions that they could develop in terms of prevention and treatment.
Results The London cohort experienced significantly higher levels of ‘disgust’ when viewing GHWL than their Singapore counterparts (smokers 74.1% vs 49.0%, p = 0.003; non-smokers 83.8% vs 57.4%, p < 0.001), and felt GHWLs were a sufficient deterrent (smokers 33.7% vs 16.3%, p = 0.029; non-smokers 71.6% vs 50.0%, p = 0.013). London non-smokers had a higher awareness of heart disease (82.4% vs 32.0%, p = 0.007), stroke (72.3% vs 28.2%, p = 0.02), mouth and throat cancer (95.6% vs 35.0%, p < 0.001) and lung cancer (98.7% vs 35.0%, p < 0.001) as smoking-related diseases. London smokers reported an increased motivation to quit if they hypothetically developed smoking-related disease (85.2% vs 72.7%, p = 0.001). Blindness was the least well-known consequence overall (27.8%), despite provoking the highest levels of fear amongst Singaporeans.
Conclusion A desensitisation effect of GHWL is observed in cohorts with an increased length of exposure, both in smokers and non-smokers. The socio-cultural background needs to be considered when running public health campaigns due to differences in perception and responses to GHWL. Investigating the awareness of risks such as blindness, that have a low knowledge score but a high deterring impact, provides the chance to create a tailored approach when addressing this desensitisation.