Background:
Pictorial health warnings (PHWs) on 80% of the cigarette packs were introduced in 2015 as the most recent method of communicating health risk of smoking in Sri Lanka.
This study aimed to evaluate the effectiveness of the newly introduced PHWs pictorial health warnings on cigarette packs among adults in a rural community.

Methods:
Cross sectional data from 360 adults (56% male) smokers and non-smokers (68%) randomly selected from rural households to complete a pre-validated self-administered questionnaire were analysed. The questionnaire collected socio-demographic data, smoking history/behavior, and exposure to antismoking media messages and newly introduced pictorial warnings, knowledge about risks of smoking and attitudes on smoking.

Results:
Majority of the respondents (91%; 87% smokers and 99% nonsmokers) reported being exposed to the pictorial health warnings (PHW) on cigarette packs.
Those who reported noticing PHWs on cigarette packs, noticing anti-smoking media messages, older age and higher education were significantly associated with higher knowledge about health risks of smoking (p< 0.05). As expected, reported noticing PHWs and knowledge about the health risks of smoking were significantly and positively associated with having negative attitudes towards smoking in both adjusted and un-adjusted regression analyses. PHWs encouraged 54% (n=131) of the non-smokers to discuss about the dangers of smoking with their family members (p=0.002) and 25% (N=29) of the smokers to have intentions to quit smoking (p>0.05).

Conclusions:
PHW on cigarette pack is a most efficient health communication tool in rural Sri Lankan community. The findings suggest that the newly introduced PHWs that cover 80% of the cigarette packs can help to increase knowledge about the harms of smoking among both smokers and nonsmokers, stimulate more conversation with significant others about the dangers of smoking among nonsmokers and encourage quitting among smokers, thus providing some support for its effectiveness as a health communication tool in rural Sri Lankan community.