Identifying credible attribution statements for sources on pictorial health warning labels in China

Background China currently uses text-only health warning labels (HWLs) on cigarette packages. Improving the design and content of cigarette HWLs is important to improve labels' credibility and effectiveness. Some countries use an attribution statement which gives an identified source for the health warnings and messages on the cigarette packaging, such as a Ministry of Health, or a public health leader such as the Surgeon General. This study tested the perceived credibility and effectiveness of four sources on HWLs in China, including the Chinese Center for Disease Control and Prevention (China CDC), the World Health Organization (WHO), the government agency of China's tobacco monopoly (STMA), and China's First Lady, Liyuan Peng (LP). Methods A cross-sectional study was conducted in 2016 with adults in 4 cities in China, including: Beijing, Shanghai, Kunming, and Wuhan (N=1,999). Study participants were shown a HWL with one of the 4 sources and asked "Which warning label appears the most credible?"; and "Which warning label appears the most effective at making people quit?", and "Which warning label appears the most effective at preventing young people from starting to smoke?" Results More than one third of respondents (36%) selected the WHO as the most credible source, followed by the China CDC (30%), STMA (24%), and LP (9%). The China CDC was perceived to be the most effective source for supporting people to quit, chosen by 38% of participants, followed by WHO (35%), STMA (18%), and LP (9%). When asked to select the most effective HWL to prevent young people from starting to smoke, 35% selected WHO, followed by China CDC (33%), STMA (18%), and LP (13%). Conclusions Using national or international public health authorities as the source for HWLs in China may help HWLs be more credible and effective at supporting quitting behaviors, and preventing young people from initiating cigarette use