Understanding the Role of Reactance to Pictorial Warnings on Cigarette Packs Public Deposited

Downloadable Content

Download PDF
Last Modified
  • March 21, 2019
  • Hall, Marissa
    • Affiliation: Gillings School of Global Public Health, Department of Health Behavior
  • Background. Pictorial cigarette pack warnings may be less effective if they elicit reactance, a motivation to resist a perceived threat to freedom. This dissertation developed and validated a brief version of the Reactance to Health Warnings Scale (RHWS). The dissertation also sought to determine the mechanisms by which pictorial warnings elicit stronger quit intentions and subsequent quit attempts, and whether reactance weakened the effect of the warnings. Methods. To develop the Brief RHWS and to test mediation, I used data from a trial that randomly assigned 2,149 adult US smokers in 2014 and 2015 to receive pictorial warnings or text-only warnings on their cigarette packs for four weeks. To further evaluate the brief RHWS, I randomly assigned US adults (n=1,413) to view pictorial or text warnings on digital images of cigarette packs. Results. The three-item Brief RHWS had good internal consistency and test-retest reliability. The scale correlated with higher trait reactance (β=.32, p<.001) and exposure to pictorial warnings (β=.21, p<.001), supporting its convergent validity. With respect to predictive validity, the Brief RHWS was associated with lower perceived message effectiveness, lower quit intentions, greater avoidance of the warnings, and more cigarettes smoked per day (all p<.05). Pictorial warnings produced stronger quit intentions (p<.05) which were associated with a greater likelihood of making a quit attempt (p<.001). Negative affect toward the warnings mediated the effect of pictorial warnings on quit intentions (mediated effect=.25, p<.001), whereas message reactance suppressed the effect (mediated effect=-.06, p<.001). Negative affect was associated with greater perceived likelihood of harm from smoking and anticipated regret of continuing to smoke, which were in turn associated with stronger quit intentions (all p<.05). Conclusion. The Brief RHWS can aid in the development of persuasive messages. Pictorial warnings elicited greater quit intentions, an effect that was stronger after accounting for message reactance. Negative affect appears to be a key mechanism by which pictorial cigarette pack warnings exert their effect on smoking-related cognitions and behaviors. Moreover, pictorial warnings changed risk appraisals and quit intentions indirectly through negative affect.
Date of publication
Resource type
Rights statement
  • In Copyright
  • Boynton, Marcella
  • Brewer, Noel T.
  • Noar, Seth
  • Sheeran, Paschal
  • Ribisl, Kurt
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2017

This work has no parents.