Graphic and Arousing? Emotional and Cognitive Reactions to Tobacco Graphic Health Warnings and Associated Quit-Related Outcomes Among Low SEP Population Groups

Mesfin Awoke Bekalu, Shoba Ramanadhan, Cabral A. Bigman, Rebekah H. Nagler, Kasisomayajula Viswanath

Research output: Contribution to journalArticle

4 Scopus citations


Research on graphic health warnings (GHWs) indicates that beyond changing cognitions about the health effects of smoking, GHWs evoke emotional reactions that can influence quit-related outcomes. Emotions can be classified based on valence (positive or negative) and arousal (calm or excited). However, although considerable research has examined the differential effectiveness of positive versus negative GHW-evoked emotions, research investigating the role of arousal activation in quit-related behaviors is scarce. This study examined associations between quit-related outcomes (intention and attempt to quit) and GHWs-evoked negative emotions classified as high and low in arousal activation as well as cognitive reactions among smokers of low socioeconomic position (SEP). It also examined whether perceived health risks of smoking moderate the relationship between emotional and cognitive reactions to GHWs and quit-related outcomes. Data were collected from low SEP smokers in three Massachusetts communities. Participants were screened and randomized to view one of the nine GHWs initially proposed for use by the U.S. Food and Drug Administration (FDA) and answered pre- and post-exposure questions. Results showed that GHW-evoked negative emotions high in arousal activation and cognitive reactions were both significantly associated with intention to quit during immediate post-test, controlling for age, warning label difference, and prior quit intention. However, these associations did not hold for quit attempts at follow-up. Perceived health risks of smoking moderated the association between cognitive reactions to GHWs and quit attempts at follow-up. The findings suggest that not all negative emotions evoked by GHWs are effective. Negative emotions high in arousal activation may be more effective in influencing quit-related behavioral intentions in low SEP groups. Additionally, unlike emotional reactions, cognitive reactions to GHWs may have effects that last relatively longer, but only among smokers who had low levels of perceived health risks of smoking at baseline.

Original languageEnglish (US)
Pages (from-to)726-734
Number of pages9
JournalHealth communication
Issue number7
StatePublished - Jun 7 2019


PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

Cite this