Graphic Cigarette Labels: A Step Backwards in Combating Nicotine Addiction

The government’s “anti-smoking campaign” follows a troubling trend of making fear laden messages the key component of health campaigns.  Photo: Marius Mellebye

MICHIGAN, March 24, 2012 - “This is your brain (an egg). This is drugs (a hot frying pan). This is your brain on drugs (one fried egg). Any questions? ” Better known as the “brain on drugs” advertisement, this infamous commercial aired frequently in the early 1990’s, as it sought to analogize a “frying egg” to the effects that drugs can have on the brain. Health promotion campaigns such as these, which utilize “fear appeals,” have become more popular and exponentially more gruesome since the egg and frying pan ad. But does this persuasive approach actually work to deter unhealthy behaviors? Highly unlikely, at least when used as the sole method, according to numerous studies conducted on this approach. In fact, a positive reinforcement approach may be more effective than fear (Job, 1988).    

The most recent example of this use of “fear appeals” to elicit behavior change is evident in the government’s “anti-smoking campaign” which uses large, grisly graphic images on cigarette packages as a method to deter or otherwise try to persuade individuals, primarily youth, to quit smoking. A pair of diseased lungs next to a pair of healthy lungs, a man breathing into an oxygen mask, a woman weeping, and cancerous lesions surrounding a diseased mouth are just some examples of the shocking and extreme images that they would like smokers to see next time they buy a pack of cigarettes. 

Graphic Cigarette Warning Label Depicting Male Cadaver with Sewn-Up Chest

The images paint a portrait of impending doom: they seem to be yelling at the purchaser of that pack of cigarettes to “QUIT NOW” or “DON’T EVEN START.” It’s as if the existing warning labels, such as “smoking can kill you,” or “tobacco causes fatal lung disease in nonsmokers” were benign and so subtle that they needed to be supplemented with grisly images. It is noteworthy to mention that these warning labels must cover the top 50 percent of a cigarette pack’s front and back panels. The images not only punish the purchaser, but they threaten them as well. This is achieved expressly through language found on the warning labels such as “smoking can kill you”, and implicitly, for example, by showing a graphic of a woman mourning.


The emotion that is “fear” triggers potent negative thoughts in our minds, and exploiting people’s vulnerability to it has become a staple ingredient of recent health campaigns, with the government’s “anti-smoking campaign” reinforcing this strategy. In fact, Merriam Webster dictionary defines fear as “an unpleasant often strong emotion caused by anticipation or awareness of danger; solicitude; danger.” Just try rehashing a scenario in your own life that made you fearful and it would surely elicit a feeling of threat, thereby inducing your anxiety and apprehension. 

Early psychological studies of animals affirmed the notion that fear, which produces an unpleasant outcome, can be used effectively to elicit a response. For example, applying an unpleasant stimulus, such as a mild electric shock, has been shown to stop rats from pressing a bar. In other words, the punishment produced, such as an electric shock, has proven to be effective as a means of stopping unwanted behaviors in both humans and animals (McLeod, 2007). 

Apparently, some designing mass media public advertisements and campaigns have looked to these studies as unequivocal, indisputable proof that “fear appeals” work.  They err, however, in using this as a conceptual framework, since health campaigns must utilize the “art of persuasion,” not physical abuse to achieve its ends. Thus, this fixation on removing the unhealthy behavior, through “fear appeals” as a punishment, should not take precedence over a strategy that attempts to introduce and emphasize the importance of healthy alternative behaviors—hence the term “health promotion.”   


Numerous studies have shown that the “fear-based campaign” fails to modify behaviors accordingly, and may even make the target of the campaign more likely to continue with the unhealthy behavior. These studies have assessed the influence of these particular campaigns on “detection” behaviors like screening for cancer, to some of the most dangerous behaviors with great societal consequences, such as drunk-driving and unsafe sex practices. 

A study by Ruiter et al. (2001) compared the impact of “high threat” versus “low threat” messages on their ability to persuade female college students to obtain breast self-examinations (BSE) and concluded that fear based campaigns only work when used in conjunction with strong, persuasive arguments in favor of the recommended action.

The study involved a sample of 88 female university students who were initially given a pre-experimental questionnaire about their attitude toward BSE. Next, they provided the participants with either a low-fear message or mild-fear message about breast cancer. The low-risk message informed participants that they would have to undergo a “lumpectomy” which is just a mild procedure involving the removal of a tumor without affecting breast itself, and had 2 accompanying images that showed only small scars after the operation. The mild-risk message group, however, were informed that they would have to undergo a procedure called a “radical mastectomy” which is removal of the breast, and had 2 accompanying images which were grisly in nature, showing the physical consequences of this procedure.  

Next, participants read a persuasive message about performing BSE, supported by either 8 weak or 8 strong arguments for getting a BSE. An example of a strong argument used in the study was “By performing BSE you are able to detect breast cancer in an earlier and therefore more treatable stage.” Notice how the strong argument did not go to the extreme of simply stating that not getting a BSE can kill you, rather it explains how getting a BSE can prevent the risk of breast cancer.    

The findings concluded that the group that received the mild fear messages accompanied by strong arguments for receiving BSE had a significantly more positive attitudinal change towards getting BSE. Yet this same group had no significant change in their attitude toward BSE when the mild fear messages were accompanied by weak arguments for receiving BSE. In other words, the group exposed to more fear through graphic images and messages were not influenced to change their behavior, unless the campaign was accompanied by strong persuasive arguments for why behavior change is important.    

Use of fear appeals has also been a core component of HIV prevention campaigns. In a study by La Tour and Pitts (1989), gay men were shown an advertisement notoriously known as part of “the grim reaper campaign of 1987,” which included vivid language on how AIDS can kill, and included provocative images of dead people. Specifically, the ominous voice in the 1987 advertisement says such things as “now we know everyone can be devastated by it;” “in 3 years, nearly 2,000 of us will be dead;”  “if not stopped, it could kill more Australians than World War II.” Indeed these are very frightening statements intended to shock. The ad made only two brief recommendations in order to prevent contracting HIV; always use condoms, and have safe sex with just one partner. 

The images are even more intense and horrific, displaying people, women and children included, as bowling pins, with the grim reaper bowling, throwing “strikes” and “spares,” and killing all the people. There is a shroud of smoke surrounding the dark bowling alley, and the people possess frightful looks on their faces, and some are even crying. The most grotesque aspect is the vivid images of the dead corpses, their faces pale, falling, and being cleared off the alley just like pins by a mechanical pinsetter. You can find the ad on YouTube if you would like to see a more extreme fear appeal ad.           

So how did this ad fare among this cohort of Australian gay men? Surprisingly, the ad produced the opposite effect of its intended purpose, and the men actually reduced safer sex behaviors following exposure. The authors concluded that the images and language were so potent and threatening, that they led to a state of denial and helplessness, and felt that there simply was no escaping contracting the AIDS virus (La Tour & Pitts, 1989). 

Health campaigns based on fear appeals targeting alcohol impaired driving (AID) among youth have also been largely unsuccessful (Prevention First, 2008). The ads often contain footage of fatal collisions followed by graphic images of the injuries sustained, and the victim or perpetrator undergoing treatment.  

Cars being “t-boned” at intersections, vehicles squashed to a fraction of their size, shattered glass everywhere, sounds of brakes screeching and metal smashing, close-ups of people being ejected from their seat, and victims faces and arms bleeding profusely, are just some of the shocking images that have become the bedrock of these campaigns. 

One ad completely skipped the scene depicting the fatal collision, and solely depicted a drunk driver on a hospital bed, breathing into a respirator, his face bludgeoned and bloody, fingers severed, and his left leg amputated. The ad takes an interesting spin in that his friend is in the room with him, and he is talking him out of drinking and driving by offering him to sleep over, or have someone drive him home. As he continues to talk to him, offering him these suggestions, his friend begins to recover, and he is restored to his original state, and ultimately gets up off the hospital bed. 

But do these scare tactics work in drunk-driving health campaigns to promote positive behavior change? 

Studies have found that these fear based campaigns found that youth engaged in numerous defense mechanisms which ultimately lead them to not want to adopt the recommended behavior such as:

  • Minimizing- A study by Hastings et al. (2004) found that because many youth have little sense of their own mortality, they tend not to respond to the fear based model, and thus believe that the negative physical consequences associated with the behavior have been exaggerated
  • Denial- People may discount the message if they believe the harmful consequences are unlikely.  For example, the target audience member may have been smoking, drinking and driving, or engaging in unprotected sex for a significant period of time and not have been injured. They then come to a conclusion that the message is wrong, or they are somehow immune (Job, 1988).
  • Ridiculing- this is when the target audience feels that the message is so absurd, that they will ignore it and simply refuse to believe it. Messages that are extremely threatening are more likely to be viewed as less credible (Prevention First, 2008).  

Health educators should be mindful of such defense mechanisms when implementing fear as a tactic. The campaign should not scare off their viewers, leading to responses such as the defense mechanisms listed above to deal with the fear. If health campaigns are to distinguish themselves from horror movies whose sole purpose is to induce fear, then it may be prudent to keep dead corpses, amputated limbs, blood gore, and other such extreme and unnerving images out of the realm of health education.  

This is not to say that fear doesn’t work; rather, the application of fear to induce one to change unhealthy behaviors is most likely to succeed when its use is not exaggerated, and it is accompanied by a set of specific actions that people can take to protect themselves from the harm (Job, 1988). 

The Obama administration’s anti-smoking campaign follows a dangerous trend by some health educators and bureaucrats who view health promotion as the removal of unwanted behaviors and relish using phrases that begin with “don’t” to induce motivation for change. However, a philosophy that focuses more upon promoting healthy alternative behaviors through a set of suggestions, with “do this” as the theme, should be the aim of health promotion campaigns. 

This strategy of inducing fear to promote healthy behaviors perpetuates a dangerous misapplication of punishment-based practices in learning. The potential harm of ineffective campaigns include the waste of time, money, and effort, and the possibility that it could actually have a reverse effect upon the target audience, making them less likely to engage in the recommended practice. It’s time to either remove the graphic images off these cigarette packs, or otherwise supplement them with suggestions for refusing cigarettes or how to quit smoking.

The ramifications of stubbornly pursuing a “punishment-based approach” are too great on the individual, and our society as a whole.  




Hastings, G., Stead, M., & Webb, J.  (2004). Fear Appeals In Social Marketing:  Strategic and Ethical Reasons for Concern.  Psychology and Marketing, 21 (11), pp. 961-986. 

Job, R.F.S. (1988). Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health, 78, pp. 163-167.

La Tour, M.S. & Pitts, R.E. (1989).  Using Fear Appeals in Advertising for AIDS Prevention in the College-age Population.  Journal of Health Care Marketing, 9 (3), pp. 5-14.

McLeod, S. A. (2007).  Simply Psychology.  Retrieved 22 March 2012, from

Prevention First.  (2008). Ineffectiveness of Fear Appeals in Youth Alcohol, Tobacco and Other Drug  (ATOD) Prevention.  Springfield, IL:  Prevention First. 

Ruiter, R. A. C., Kok, G., Verplanken, B., & Brug, J. (2001).  Evoked Fear and Effects of Appeals on Attitudes to Performing Breast Self-Examination: an Information Processing Perspective.  Health Education Research, 16 (3), pp. 307-319.   

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Michael Janati

Michael Janati is a certified personal trainer through the American Council on Exercise, and CPR/AED certified through the American Red Cross.  He has an undergraduate degree in Psychology, and a Masters of Science in Health Promotion Management.

Michael has worked as a fitness manager for a large commercial gym, and has experience training a variety of clientele.  During his employment at an outpatient day program for clients diagnosed with severe mental illnesses, he conducted fitness outings and health/wellness groups.  There, he played an integral role in helping motivate clients to become active as a means of coping with their illnesses.

Michael is competitive in races, having successfully completed a half-marathon, sprint triathlon, an indoor triathlon, as well as a number of 5Ks.  He enjoys running, swimming, tennis, strength-training, flag football, and bowling.   

Currently, he resides in Michigan, where he is working towards his Juris Doctorate.



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