Brain scans show that viewing graphic anti-smoking images on cigarette packs activates areas involved in emotion, decision-making, and memory, researchers report in Addictive Behaviors Reports.
Researchers from Georgetown University Medical Center and Truth Initiative used functional magnetic resonance imaging (fMRI) to study neural responses in young adult smokers exposed to graphic warning labels on cigarette packs. The findings suggest that these graphic images can engage brain systems tied to emotional reaction, self-relevance and memory formation, which may help explain why such warnings encourage quitting, according to Darren Mays, PhD, MPH, assistant professor of oncology at Georgetown Lombardi Comprehensive Cancer Center and co-lead author of the study.
“This study builds on prior research that asked smokers how they felt about graphic warnings,” Mays said. “By showing the neural mechanisms behind those reactions, we gain new insight into how these warnings can influence thinking and behavior.”
The study tested 19 smokers aged 18 to 30. Participants viewed 64 images of cigarette packs for four seconds each. Some images included graphic warnings proposed by the U.S. Food and Drug Administration—images and text that convey risks such as cancer, lung disease, stroke, heart attack and shortened lifespan—while other images were visually occluded control warnings. The packs also varied by branding, with some images showing branded packaging and others showing plain packs without logos or imagery.
Cognitive neuroscientist Adam Green, PhD, the study’s other co-lead investigator, explains which brain regions responded: “We observed notable activation in the amygdala and the medial prefrontal cortex. The amygdala is highly responsive to emotionally powerful stimuli—particularly fear and disgust—while medial prefrontal regions are involved in processing information that feels personally relevant. Information perceived as self-relevant is more likely to affect decision-making.”
After each image presentation, participants rated how much the image motivated them to quit smoking on a four-point scale from 1 (not at all) to 4 (a lot). Self-reported motivation to quit was significantly higher for graphic warning labels than for control warnings (p < .001), a result that matched neural activation patterns observed in the scans. fMRI data revealed stronger blood oxygenation level–dependent (BOLD) responses to graphic warnings than controls in clusters including the medial prefrontal cortex, amygdala, medial temporal lobe, and occipital cortex. The study reported no significant differences in neural response between branded and plain packaging.
These findings align with previous neuroimaging research conducted in adolescents and older adults, indicating that similar brain regions are activated by graphic warning labels across age groups of smokers. “As evidence accumulates, the case grows stronger that graphic warnings are a meaningful public health tool to motivate cessation,” Mays said.
Raymond S. Niaura, PhD, senior author and director of Science at the Schroeder Institute for Tobacco Research and Policy Studies at Truth Initiative, emphasized the policy implications: “Regulators can use this research to design warning labels that not only present facts about the harms of smoking but also trigger the kinds of thoughts and emotions that lead smokers to take steps toward quitting. Tobacco remains the leading preventable cause of death in the U.S.; this growing body of evidence should guide and energize policymaking.”
Participants: 19 young adult smokers (mean age 22.9; 52.6% male; 68.4% non-white; mean 4.3 cigarettes/day).
Methods: Pre-scan self-report measures assessed demographics, smoking behavior and nicotine dependence. During fMRI scanning, participants viewed 64 cigarette pack images (4 seconds each) that varied by warning type (graphic vs. visually occluded control) and packaging (branded vs. plain). Motivation to quit was recorded for each image. Whole-brain BOLD functional images were acquired during the task.
Key results: Graphic warning labels produced significantly greater self-reported motivation to quit than control warnings (p < .001). Imaging data showed stronger neural activation for graphic warnings in medial prefrontal cortex, amygdala, medial temporal lobe and occipital cortex. Packaging branding did not significantly alter neural responses to the warnings.
Conclusions: In this sample of young adult smokers, graphic warning labels engaged brain regions involved in affective and cognitive decision-making and memory formation. The similar neural activation patterns across different age groups and smoking populations strengthen the argument that graphic warnings are an effective component of tobacco control strategies.
Co-authors include Emily Falk, PhD (University of Pennsylvania); Donna Vallone, PhD; David Abrams, PhD (Truth Initiative); and Natalie Gallagher and Kenneth Tercyak, PhD (Georgetown University).
Funding: Data collection was supported in part by a contract from Truth Initiative. Manuscript preparation received partial support from the National Institutes of Health and the Food and Drug Administration Center for Tobacco Products (CA172217). Additional support came from the Georgetown Lombardi Comprehensive Cancer Center Support Grant (P30CA051008).
Research citation (original): “Young adult smokers’ neural response to graphic cigarette warning labels” by Adam E. Green, Darren Mays, Emily B. Falk, Donna Vallone, Natalie Gallagher, Amanda Richardson, Kenneth P. Tercyak, David B. Abrams, and Raymond S. Niaura. Published online February 13, 2016 in Addictive Behaviors Reports.
These findings contribute to a broader evidence base on how graphic health warnings can influence motivation and behavior by engaging emotional and self-referential brain circuits. The authors suggest that regulators and public health officials consider this neurobiological evidence when crafting warning labels to reduce tobacco use and related harm.