Background:
Cigarette pictorial health warning labels (HWLs) are more effective than text-only HWLs at increasing cessation intention. Measuring indicators of HWL effectiveness, such as salience of HWLs, thinking about the health risks of smoking, thinking about quitting smoking, avoidance of HWLs, perceived risk of smoking, and likelihood of forgoing next cigarette can help explain how viewing HWLs impacts cessation intention. Our aim was to conduct a pre-post analysis of these indicators to evaluate how pictorial HWL textual framing (factual - vs. personal-text) and depictions of harm (smoking - vs. secondhand smoke-related harms) encourage cessation intention.

Methods:
A cross-sectional randomized experimental survey was conducted during 2016 in four Chinese cities: Beijing, Shanghai, Wuhan, and Kunming. Adult smokers (n=1612) answered questions regarding indicators of effectiveness of the current text-only HWLs in China, were presented eight pictorial HWLs with factual - or personal-text and depictions of smoking - or secondhand smoke-related harms, and answered questions regarding indicators of pictorial HWL effectiveness. T-tests were conducted to compare differences between current text-only and pictorial HWL indicators.

Results:
Reported salience, thinking about health risks, thinking about quitting, avoidance, perceived risks, and likelihood of forgoing next cigarette significantly increased after viewing the personal pictorial HWLs (each test, p< 0.01). Similar results were found for factual pictorial HWLs; however, avoidance of factual pictorial HWLs with depictions of smoking - or secondhand smoke-related harms was unchanged (p=0.1 and p=0.6, respectively).

Conclusions:
All reported indicators of HWL effectiveness increased after viewing pictorial HWLs with the exception of avoidance of factual pictorial HWLs suggesting that both personal and factual pictorial HWLs depicting smoking or secondhand smoke-related harms are effective at encouraging cessation intention. Future studies can use these indicators as tools to identify the most effective and culturally relevant pictorial HWLs for Chinese smokers.