Background:
Graphic health warning labels demonstrate effectiveness, particularly for low- and middle-income countries. This study examined six recommended health warning labels, three of which include gruesome imagery and three relatively benign imagery, in a sample of 1,163 adults in Georgia, a middle-income country with high smoking prevalence. We examined: 1) each of these graphical warning labels to text only as well as to one another in terms of “effectiveness in motivating smokers to quit or preventing people from starting smoking”; and 2) prevalence and correlates of rating gruesome (versus benign) images as more, effective, or equally effective.

Methods:
We conducted a split-half experimental design in the context of a national survey, whereby participants were asked to rate two different sets of text and graphical warning labels.

Results:
Gruesome images were rated as more effective than text and benign images (p's< .001); only one benign image was rated as more effective than text (p=.003). While 43.8% rated gruesome images more effective on average, 43.4% rated gruesome and benign images equally effective (no difference), and 12.9% rated benign images as more effective. Nominal logistic regression indicated that, compared to those rating the images equally effective (referent group), those reporting benign images more effective had higher monthly income (p=.034) and fewer friends who smoked (p=.042); no significant predictors of rating gruesome images as more effective were identified (R-squared=.058). Among current smokers, compared to those rating the images equally effective, those reporting benign images as more effective rated quitting smoking as more important (p=.006) and were older at age of initiation (p=.023); those reporting gruesome images more effective had lower household income (p=.002), were less likely to have children (p=.05), and were more likely to be unemployed (p=.05; R-squared=.534).

Conclusions:
Gruesome imagery is not more effective for all people; understanding the effectiveness in different populations is critical.