Introduction:
Survey data shows that 19.9% of students aged 13-15 had tried smoking and 30.0% of them became addicted in China. Graphic tobacco package warnings are an effective method to raise awareness of smoking dangers among adolescents and non-smokers. However, cigarette packages only include vague text warnings in China. Little domestic research has explored the cigarette package warning effects on teenagers.

Objectives:
We hope this study can find which package designs have the best effect to prevent Chinese teenagers from smoking, thus providing evidence to advocate for adopting effective package warnings in China.

Methods:
A self-administered questionnaire survey was conducted from 1238 students aged 12-18 from 2 schools in Huangpu district of Shanghai. Eight kinds of cigarette packages were shown in the questionnaire with different designs of background and warning labels. The effects such as increasing awareness of tobacco dangers, arousing an emotional response and commitment to not smoke were evaluated through rating for each package and ranking the different designs.

Results:
Among 1238 students, 16.96% had tried smoking and 7.84% smoked in the past 30 days. The plain designed package with a picture of a real dying patient and a warning label stating, “Smoking can kill you” had the strongest warning effect on teenagers, and was thought to be the most effective in preventing teenagers from smoking. The current cigarette package design with commercial logo and vague text stating, “Adolescents shouldn’t smoke” had the least effectiveness. Meanwhile, 68.99% of students support adopting disease photos on tobacco packages, and 58.72 % students thought cigarette packages should include more specific health messages. Also, 81.58% of students support increasing the graphic warning area to over 70% of the total.

Conclusion(s):
The current cigarette package in China has the least effectiveness in preventing teenagers from smoking. Graphic warning packages with real pictures with clear warning labels in plain design should be adopted in China.

Funding:
This study is supported by the National Natural Science Foundation of China [71573047].