Background:
There is no current nationally representative study to inform whether pictorial warnings will have an influence on smoking among South Africans. This study therefore sought to determine the perception of South African adult smokers of pictorial warnings on quitting behaviour.

Methods:
The study involved a nationally representative sample of adults ≥16 years (N=3,063) who participated in the 2016/2017 South African Social Attitudes Survey (SASAS). Using a self-administered questionnaire, data obtained include socio-demographics, tobacco use and notice of health warnings. Also obtained were participants' perception of counter displays on encouraging youth smoking, and if participants felt current text warning can make smokers think about quitting. The respondents were then showed model pictorial warning packs and asked the extent they felt this could make smokers think about quitting.

Results:
Current smoking among South African adults in 2016 was 19% (95%CI=16.9-21.3; n=597) and only 35.3% (n=1120) frequently noticed current text health warnings, while 58.2% (n=1794) agreed that counter displays will encourage youth smoking. Of the smokers, only 50.5% (n=338) plan to quit and 60% (n=361) had attempted to quit. Although, 85.7% agreed that text warnings were easy to understand, only 15.1% felt this would make a smoker think of quitting. However, 41.9% felt that the pictorial warnings would make smokers think of quitting. Those who felt pictorial would prompt quitting were also more likely to believe sales counter displays may encourage youth smoking (OR=3.13; 95%CI=1.82-5.37), have made a quit attempt in the last 12 months (OR=1.88; 95%CI=1.07-3.30) and less likely to be current e-cigarette user (OR=0.21; 95%CI=0.06-0.83). Compared to those with Grade 12 education, those with < Grade 12 (OR=1.72; 95%CI=1.00-2.96) and >Grade 12 (OR=3.78; 95%CI=1.50-9.53) were more likely to feel pictorial warnings would prompt quitting.

Conclusions:
These findings suggest that adding pictorial warnings to the current cigarette packs is more likely to prompt quitting.