Graphic health warnings as activators of social networks: A field experiment among individuals of low socioeconomic position

Shoba Ramanadhan, Rebekah H. Nagler, Rachel McCloud, Racquel Kohler, Kasisomayajula Viswanath

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Rationale Graphic health warnings (GHWs) on cigarette packages present an important tobacco control opportunity, particularly for vulnerable populations suffering a disproportionate tobacco burden. One mechanism by which GHWs may influence smoking outcomes is by prompting interpersonal discussions within health discussion networks (the set of personal contacts with whom an individual discusses health issues). Objective The study examined the association between GHW-prompted conversations within health discussion networks and key tobacco-related outcomes, with attention to valence and content of the discussions. Method Between August 2013 and April 2014, we recruited 1200 individuals from three communities in Massachusetts, emphasizing recruitment of individuals of low socioeconomic position (SEP) and members of other selected vulnerable groups. Respondents were exposed to the nine GHWs proposed by the FDA in 2011, asked a series of questions, and assessed at follow-up a few weeks later. Results A total of 806 individuals were included in this analysis. About 51% of respondents reported having a health discussion network, with significantly lower reports among African-Americans and Hispanics compared to Whites. Around 70% of respondents (smokers and nonsmokers) with health discussion networks reported having one or more conversations about the GHWs with network members, the bulk of which were negative and focused on warning others about smoking. For smokers, we found a small but positive association between the percentage of network conversations that were negative and reports of quit attempts. Conclusion The results point to a potential mechanism by which GHWs may impact tobacco-related outcomes, prompting further inquiry into the role of health discussion networks (and discussion networks, more broadly) in tobacco control among low SEP individuals.

Original languageEnglish (US)
Pages (from-to)219-227
Number of pages9
JournalSocial Science and Medicine
StatePublished - Feb 1 2017

Bibliographical note

Funding Information:
The authors thank our community partners in Boston, Lawrence, and Worcester, MA for their assistance and support in recruiting and retaining study participants. The study was funded by the National Cancer Institute (3P50CA148596-03S1, Viswanath Study PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors also thank three anonymous reviewers for their insightful comments and critiques.


  • Egocentric
  • Graphic health warnings
  • Low socioeconomic position
  • Social networks
  • Tobacco

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