Label Accuracy of Legal Oral Cannabis Oil Products in Ontario, Canada.

This case series compares amounts of tetrahydrocannabinol and cannabidiol reported on product labels vs levels found in laboratory testing in legal oral cannabis oil products in Ontario, Canada.

Labelling and composition of contraband electronic cigarettes: Analysis of products from Australia.

BACKGROUND: The sale of nicotine-containing electronic cigarettes (e-cigarettes) is prescription only in Australia, regulated under the Standard for Nicotine Vaping Products (TGO110). Australian e-cigarette users, however, are purchasing e-cigarette products outside of the intended pathways. METHODS: The labelling of e-cigarette packaging (N = 388 boxes) and the chemical composition of disposable e-cigarettes and pods (N = 428) were analysed for adherence to the current Australian regulations. These samples were confiscated from over-the-counter retailers in NSW by the NSW Ministry of Health during 2022 for non-compliance with Australian regulations. RESULTS: Following the announcement of the prescription only model for nicotine-containing e-cigarettes in Australia in mid-2021 there was a clear shift in the labelling of products. Any mention of the word 'nicotine' was removed from e-cigarette packaging by early 2022 and nicotine warnings were replaced with generic underage sale warnings. Despite this labelling, the vast majority (98.8 %) of devices analysed contained nicotine, most (89 %) at high concentration (>30 mg/mL) and 4.2 % contained at least one chemical prohibited by the TGO110. CONCLUSIONS: It appears that manufacturers have removed any mention of nicotine from the original packaging of nicotine-containing disposable e-cigarettes to circumvent restrictions on nicotine-containing products and continue their sale. The packaging of e-cigarette products in Australia is generally not indicative of their contents, particularly nicotine, and most did not display required warnings. Ingredients with associated health risks, prohibited in legal vapes by the TGO110, were found in samples. Consequently, the risks of e-cigarette use cannot be appropriately identified from the information supplied on the packaging or device.

Exploring the effects of cannabis health warnings on protective health intentions among US adults in legal recreational states.

BACKGROUND: As cannabis policy trends toward liberalization, assessing cannabis health warning effects becomes increasingly important. This study investigated underlying mechanisms accounting for the effectiveness of cannabis health warnings on protective health intentions. METHOD: A sample of 1,095 adults (21+) living in legal recreational US states who reported using cannabis in the past 12 months participated in an online experiment. Participants were randomly assigned to view cannabis health warnings that described risks of impaired driving, mental health, and smoke exposure and varied pictures and text (vs. text-only) attributes in warnings. Outcomes were message reactions (cognitive elaboration, fear, and hope), attitudes and beliefs (perceived severity of cannabis harms and perceived susceptibility to cannabis harms, and perceived response and self-efficacy to prevent cannabis harms), and protective health intentions (information-seeking about cannabis health effects and having interpersonal discussions about cannabis harms with family, friends, and medical professionals). RESULTS: MANCOVA results showed no significant differences between text-only vs. pictorial attributes on protective health intentions; thus, warning conditions were controlled and analyzed using structural equation modeling (SEM). SEM results showed that attention to cannabis health warnings (text-only or pictorial) elicited higher cognitive elaboration, fear, and hope-an emotion associated with coping actions that motivate positive expectations of future events. These outcomes, in turn, were associated with greater perceived severity and susceptibility and greater perceived response efficacy, respectively. Hope, perceived severity, and perceived response and self-efficacy were independently associated with greater intentions to seek information about cannabis health effects and to discuss cannabis health harms. CONCLUSION: Attention to warnings impacted emotions, attitudes, and protective health intentions. Fear is commonly associated with health warning effects, and our results suggest that hope is also an important factor. This research contributes to understanding the effects of cannabis health warnings and can inform regulatory agencies that mandate warnings on cannabis products.

Qualitative analysis of front-of package labeling policy interactions between stakeholders and Health Canada.

Background: Front-of-package labelling regulations proposed by Health Canada in their Healthy Eating Strategy (2016) were finally passed in 2022, but remain unimplemented. This study analyzed interactions that occurred between stakeholders and government related to this policy proposal to identify key themes and policy implications. Methods: A qualitative framework analysis was conducted on publicly available documents for stakeholder correspondences related to front-of-package that occurred between 2016 and 2019 in Health Canada's Meetings and Correspondence on Healthy Eating database. Five sequential steps were applied: familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation. A complex systems (i.e., a dynamic system with multiple interconnecting components) lens was incorporated in the final step to deepen the analysis. Results: Hundred and seventy-three documents were included, the majority from industry stakeholders (n = 108, 62.4%). Three overarching themes were identified: industry trying to control the agenda and resist regulation; questioning the evidence supporting the policy and its impact on the agri-food industry; and dismissing the need and effectiveness of the policy. Incorporating a complex system lens found industry and non-industry stakeholders held markedly different perspectives on how cohesive the system defined by the front-of-package labelling policy was, and the policy impact on its stability. Economic and opportunity costs were the main trade-offs, and symbol misinterpretation considered an unintended consequence by industry. Finally, some stakeholders argued for wider policy scope incorporating more products, while others requested a narrower approach through exemptions. Conclusion: Interactions with industry stakeholders on health food policy proposals require careful consideration, given it may suit their interests to generate delays and policy discordance. Explicitly setting out the principles of engagement and actively encouraging non-industry stakeholder representation provides a more balanced approach to policy consultation and development.

Industry influence over global alcohol policies via the World Trade Organization: a qualitative analysis of discussions on alcohol health warning labelling, 2010-19.

BACKGROUND: Accelerating progress to implement effective alcohol policies is necessary to achieve multiple targets within the WHO global strategy to reduce the harmful use of alcohol and the Sustainable Development Goals. However, the alcohol industry's role in shaping alcohol policy through international avenues, such as trade fora, is poorly understood. We investigate whether the World Trade Organization (WTO) is a forum for alcohol industry influence over alcohol policy. METHODS: In this qualitative analysis, we studied discussions on alcohol health warning labelling policies that occurred at the WTO's Technical Barriers to Trade (TBT) Committee meetings. Using the WTO Documents Online archive, we searched the written minutes of all TBT Committee meetings available from Jan 1, 1995, to Dec 31, 2019, to identify minutes and referenced documents pertaining to discussions on health warning labelling policies. We specifically sought WTO member statements on health warning labelling policies. We identified instances in which WTO member representatives indicated that their statements represented industry. We further developed and applied a taxonomy of industry rhetoric to identify whether WTO member statements advanced arguments made by industry in domestic forums. FINDINGS: Among 83 documents, comprising TBT Committee minutes, notifications to the WTO of the policy proposal, and written comments by WTO members, WTO members made 212 statements (between March 24, 2010, and Nov 15, 2019) on ten alcohol labelling policies proposed by Thailand, Kenya, the Dominican Republic, Israel, Turkey, Mexico, India, South Africa, Ireland, and South Korea. WTO members stated that their claims represented industry in seven (3·3%) of 212 statements, and 117 (55·2%) statements featured industry arguments. Member statements featured many arguments used by industry in domestic policy forums to stall alcohol policy. Arguments focused on descaling and reframing the nature and causes of alcohol-related problems, promoting alternative policies such as information campaigns, promoting industry partnerships, questioning the evidence, and emphasising manufacturing and wider economic costs and harms. INTERPRETATION: WTO discussions at TBT Committee meetings on alcohol health warnings advanced arguments used by the alcohol industry in domestic settings to prevent potentially effective alcohol policies. WTO members appeared to be influenced by alcohol industry interests, although only a minority of challenges explicitly referenced industry demands. Increased transparency about vested interests might be needed to overcome industry influence. FUNDING: None.

Transfer of chemicals to a secondary container, from the introduction of new labelling regulation to COVID-19 lockdown: A retrospective analysis of exposure calls to the Poison Control Centre of Rome, Italy, 2017-2020.

The transfer of a chemical product from its original container to an unlabelled secondary container by consumers is a potential health hazard that may result in unintentional exposures and intoxications. The aim of this study was to describe the pattern of prevalence of exposures to transferred products in Italy from year 2017, when the new European labelling regulation for chemicals became fully operative, to 2020, year of the coronavirus 19 disease first outbreak. Calls to the Poison Control Centre (PCC) of Policlinico Umberto I Hospital - Sapienza University of Rome were analysed retrospectively for characteristics, clinical presentation and circumstances related to the event. We registered 198 cases of interest. There was a reduction in cases from 2017 (4.9%) to 2019 (2.2%), followed by an increased prevalence in 2020 (4.2%) mainly due to the months "post-lockdown." The transferred product was very frequently diluted, and an empty drinking bottle was usually used as secondary container. Exposures were mostly of minor severity, and no deaths occurred. The study highlights the importance of PCCs data in the evaluation of the hazard communication to users through labels and advises for public campaigns to promote safe behaviours during future lockdowns to prevent exposures at a later period.

Evidence of the Effectiveness of Pictorial Health Warnings on Cigarette Packaging in Nepal.

BACKGROUND: Tobacco Control Act of 2010 mandates government to implement at least 75% pictorial health warnings (PHWs) on tobacco packaging that was enforced in 2013. The purpose of the study was to assess the effectiveness of PHWs and its impact to the policy change. METHODS: A cross-sectional study was conducted in 9 cities between September 2014 and March 2015. Direct interviews were made among 2250 randomly selected individuals. The effectiveness of PHWs were measured as perceived: i) scariness; ii) quit motivation iii) convincing youth not to start smoking; iv) encouraging ex-smokers to remain as quitters; v) building public awareness. Logistic regression analysis was used to determine the factors associated with the effectiveness of PHWs. RESULTS: Of the 2250 participants, 29.8% (670) were current smokers, 8.6% (193) were ex-smokers and 97.6% believed that smoking was addictive. PHWs made 83% of the participants scared. Participants believed that PHWs would be effective in motivating smokers to quit (80.2%), in convincing youth not to start smoking (86.8%), in encouraging ex-smokers to remain as quitters (89.1%) and in building public awareness on the dangers of smoking (94%). PHWs made 58% of the current smokers intended to quit smoking and reduced their daily intake of cigarettes from 11 to 5 on average.  Current smokers preferred to purchase loose cigarettes rather than a pack. The covariates significantly associated with the effectiveness of PHWs were current smokers, ex-smokers and addiction. CONCLUSION: PHWs were found important to motivate smokers to quit smoking, to reduce consumption of cigarettes and to prevent relapse in ex-smokers. Evidence from the study had triggered policy changes which included enlargement of the size of PHW to 90% and the release of a notification to ban selling of loose cigarettes. Thus, the warning messages with pictures are required to be improved and rotated.

Health Warning Label Compliance for Smokeless Tobacco Products and Bidis in Five Indian States.

BACKGROUND: The burden of tobacco use In India is very high. To inform users of harm, India has a strong health warning label law that applies to all tobacco products. This study examines the extent of compliance of health warning labels on smokeless tobacco (SLT) and bidi products with the Indian law. METHODS: In 2017, a systematic protocol was used to collect unique SLT and bidi packages from five Indian states. To assess compliance, we used three indicators: location, label elements, and warning size. RESULTS: Only 1% of the 133 SLT products and none of the 32 bidi packs were compliant with all three compliance indicators. Other compliance-related issues included non-standardized packaging, incomplete health warning labels, poor printing quality, and old warning labels. CONCLUSION: There is very poor compliance with the health warning label law on bidi and SLT products. India needs to regularly monitor and address implementation to ensure that warning labels are effective.

Implementation of MPOWER Package in the South-East Asia Region: Evidence from the WHO Report on the Global Tobacco Epidemic (2009-2021).

The WHO MPOWER package is a set of six evidence-based and cost-effective measures which was introduced on 7 February 2008 to facilitate the implementation of the provisions of the WHO Framework Convention on Tobacco Control at the ground level. These measures are: Monitoring tobacco use and prevention policies (M); Protecting people from tobacco smoke (P); Offering help to quit tobacco use (O); Warning about the dangers of tobacco (W); Enforcing bans on tobacco advertising, promotion and sponsorship (E); and Raising taxes on tobacco (R). Since its launch, the MPOWER package has become the guiding principle for all the countries of the South-East Asia Region in their crusade against the tobacco epidemic. This review article tracks the implementation of the MPOWER measures in the 11 member countries of the Region based on the last seven WHO Report on the Global Tobacco Epidemic (GTCR), i.e., GTCR2/2009-GTCR8/2021. This is with an aim to enable the countries to review their progress in implementing the MPOWER measures and to take steps to improve their advancement towards reducing the demand for tobacco products at the country level.

Regulation of Sun Protection Products in the EU.

Unlike more "traditional" cosmetic products, sunscreens do not sit inertly on the skin, providing a simple decorative effect. Their recognized and important contribution to public health has led many regions in the world to treat them as drugs or special cosmetics. Against the trend at that time, in 1976, the EU legislator already took a conscious decision to treat and regulate sunscreens as fast-moving consumer products. Since then, the EU Cosmetics Directive/Regulation balances the need for strict safety and efficacy requirements, with need for rapid innovation and easy consumer availability. Whilst the EU Regulation considers that "all cosmetic products are equal," sunscreens are clearly "more equal." In several areas of the legislation, specific requirements or guidance for sunscreen products have been introduced over the years. Whilst staying in the overall spirit of the legislation, these requirements take into account the specificity of sunscreens with regard to ingredient safety (positive list for UV filters), product safety assessment (photostability, deliberate exposure to UV light), minimum efficacy (UVA/UVB), efficacy testing (standardized test methods) and labelling (clear use instructions, non-misleading information to consumers). The article presents the history of the EU Cosmetics Regulation, its main requirements, where applicable, and specific considerations relating to sunscreens are highlighted and explained.

Nature and Potential Impact of Alcohol Health Warning Labels: A Scoping Review.

Alcohol is toxic to human health. In addition to providing nutritional information, labels on alcohol products can be used to communicate warnings on alcohol-related harms to consumers. This scoping review examined novel or enhanced health warning labels to assess the current state of the research and the key studied characteristics of labels, along with their impact on the studied outcomes. Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched between January 2010 and April 2021, and 27 papers were included in the review. The results found that most studies were undertaken in English-speaking populations, with the majority conducted online or in the laboratory setting as opposed to the real world. Seventy percent of the papers included at least one cancer-related message, in most instances referring either to cancer in general or to bowel cancer. Evidence from the only real-world long-term labelling intervention demonstrated that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Alcohol health warning labels should be seen as tools to raise awareness on alcohol-related risks, being part of wider alcohol policy approaches.

Government Options to Reduce the Impact of Alcohol on Human Health: Obstacles to Effective Policy Implementation.

Evidence for effective government policies to reduce exposure to alcohol's carcinogenic and hepatoxic effects has strengthened in recent decades. Policies with the strongest evidence involve reducing the affordability, availability and cultural acceptability of alcohol. However, policies that reduce population consumption compete with powerful commercial vested interests. This paper draws on the Canadian Alcohol Policy Evaluation (CAPE), a formal assessment of effective government action on alcohol across Canadian jurisdictions. It also draws on alcohol policy case studies elsewhere involving attempts to introduce minimum unit pricing and cancer warning labels on alcohol containers. Canadian governments collectively received a failing grade (F) for alcohol policy implementation during the most recent CAPE assessment in 2017. However, had the best practices observed in any one jurisdiction been implemented consistently, Canada would have received an A grade. Resistance to effective alcohol policies is due to (1) lack of public awareness of both need and effectiveness, (2) a lack of government regulatory mechanisms to implement effective policies, (3) alcohol industry lobbying, and (4) a failure from the public health community to promote specific and feasible actions as opposed to general principles, e.g., 'increased prices' or 'reduced affordability'. There is enormous untapped potential in most countries for the implementation of proven strategies to reduce alcohol-related harm. While alcohol policies have weakened in many countries during the COVID-19 pandemic, societies may now also be more accepting of public health-inspired policies with proven effectiveness and potential economic benefits.

Posicionamiento sobre la definición de azúcares añadidos y su declaración en el etiquetado de los productos alimenticios en España / Position statement on the definition of added sugars and their declaration on the labelling of foodstuffs in Spain

Introducción: actualmente existe una gran preocupación relacionada con el contenido de azúcares de los alimentos y bebidas ya que un consumo excesivo se asocia con una mayor prevalencia de enfermedades crónicas no transmisibles. Además, hay una gran confusión tanto en los datos científicos publicados como en las informaciones que aparecen en los medios de comunicación sobre diversos conceptos tales como azúcares libres, azúcares intrínsecos o endógenos y azúcares añadidos a los alimentos, así como sobre el tipo de monosacáridos y disacáridos que forman parte de ellos. El término azúcares libres se refiere a aspectos de salud pública mientras que el de azúcares añadidos se relaciona con la información nutricional incluida en el etiquetado regulado en el Reglamento 1169/2011, aplicable a la información alimentaria facilitada al consumidor. Material y métodos: análisis de la legislación vigente en la Unión Europea y en España, así como en Estados Unidos y México, junto con los posicionamientos de la Organización Mundial de la Salud (OMS), la European Food Safety Authority (EFSA) y la Agencia Española de Seguridad Alimentaria y Nutrición (AESAN), así como de sus comités científicos sobre la definición y declaración de azúcares totales, azúcares libres y azúcares añadidos. Resultados: los azúcares añadidos se declaran en el etiquetado en países como en Estados Unidos y México. En el caso de Estados Unidos hay una propuesta de modificación del porcentaje que deben contribuir a la dieta, pasando del 10 % al 6 %. En el caso de la Unión Europea solo está establecida la ingesta de referencia para los hidratos de carbono: 45-65 %, al igual que ya lo ha hecho el Comité Científico de la AESAN. Solo en el caso del estudio ANIBES hay un dato aproximado del consumo de azúcares añadidos para la población española: un 7,3 %. (AU)

Introduction: there is currently great concern about the sugar content of food and beverages as excessive consumption is associated with a higher prevalence of chronic non-communicable diseases. In addition, there is a great deal of confusion both in published scientific data and in media reports about various concepts such as free sugars, intrinsic or endogenous sugars, and sugars added to food, as well as the type of monosaccharides and disaccharides that are part of them. The term "free sugars" refers to public health aspects whereas the term "added sugars" relates to the nutritional information included in the labelling covered by Regulation 1169/2011 as applicable to food information provided to the consumer. Material and methods: an analysis of the legislation in force in the European Union and Spain, as well as in the United States and Mexico, together with the position statements of the World Health Organization (WHO), the European Food Safety Authority (EFSA), and the Spanish Agency for Food Safety and Nutrition (AESAN), as well as their Scientific Committees on the definition and declaration of total sugars, free sugars, and added sugars. Results: added sugars are declared on the label in countries such as the United States and Mexico. In the case of the United States, there is a proposal to modify the percentage they should contribute to the diet from 10 % to 6 %. In the case of the European Union, only the reference intake for carbohydrates is established: 45-65 %, as has already been done by the Scientific Committee of AESAN. Only in the case of the ANIBES study is there an approximate figure for the consumption of added sugars by the Spanish population: 7.3 %. (AU)

Graphic Cigarette Warning Labels, the First Amendment, and Public Right to Accurate Public Health Information: Graphic Cigarette Warning Labels Back Under Legal Scrutiny.

Importance: The 2009 Family Smoking Prevention and Tobacco Control Act required the US Food and Drug Administration (FDA) to issue a rule requiring graphic warning labels depicting the health consequences of smoking for prominent placement on cigarette packages and advertising. The tobacco industry filed a lawsuit against the FDA claiming that the required graphic labels constituted compelled speech in violation of First Amendment speech rights, and courts ruled for the tobacco industry. Subsequently, the FDA thoroughly redesigned the graphic labels and issued a revised rule, but the tobacco industry immediately filed a similar lawsuit against the FDA again on First Amendment grounds. Observations: This article examines the delicate balance between First Amendment speech rights vs the right of the public to receive truthful, accurate, and understandable public health information. The article argues that the newly designed warning labels should easily pass First Amendment analysis. The need for new warning labels on tobacco products and advertising is a critical public health intervention to promote greater public understanding of the negative consequences of cigarette smoking, especially among the young. Conclusions and Relevance: The legal analysis in this article marshals arguments that the First Amendment does not prohibit the requirement of the new tobacco warning labels. Commercial speech receives First Amendment protection primarily for the benefit of the public (listeners) and not the tobacco industry (compelled speakers). The balance favors the right of the public to receive accurate information about critical health risks.

Health-related claims in food supplements endorsements: a content analysis from the perspective of EU regulation.

OBJECTIVES: Based on the legal framework regulating the advertisement of food supplements in the EU, the aim of this article is to analyse the relationship between the presence of endorsers, the different types of health-related claims (H-RCs) and product content information. STUDY DESIGN: We applied a quantitative approach based on the content analysis of all radio spots broadcast throughout 2017 on full-service radio stations in Spain. METHODS: A corpus of 10,556 radio spots was obtained of the three radio stations with the highest audience levels (165 without repetitions). We incorporated data on the accumulated broadcast frequencies to supplement the content analysis specific to each radio spot with its weight in relation to the overall advertising discourse. We developed a coding scheme to assess the type of endorser, the types of H-RCs, and the product content information. RESULTS: Results show that European directives are breached in different ways. Healthcare experts prevail in disease claims, although they are prohibited. Celebrities are the most widely used endorsers (25%) in the function and reduction of disease risk claims. In addition, although these types of claims require substantiation by authorised ingredient, 73% of H-RCs lack this information. CONCLUSIONS: The high presence of illicit H-RCs and endorsers, such as physicians, and the omission of compulsory product information suggest that public administrations must apply stricter monitoring and sanctioning mechanisms to dissuade advertisers from further breaches of the law and to protect consumers. Implications for public health policy are made.

Should Graphic Warning Labels Proposed for Cigarette Packages Sold in the United States Mention the Food and Drug Administration?

INTRODUCTION: Under the US Family Smoking Prevention and Tobacco Control Act, the US Food and Drug Administration (FDA) has the authority to implement graphic warning labels (GWLs) on cigarette packages. Neither the original labels proposed by the FDA nor the revised labels include a source to indicate sponsorship of the warnings. This study tests the potential impact of adding a sponsor to the content of GWLs. METHODS: We recruited adult smokers (N = 245) and middle-school youth (N = 242) from low-income areas in the Northeastern US. We randomly assigned participants to view one of three versions of the original FDA-proposed warning labels in a between-subjects experiment: no sponsor, "US Food and Drug Administration," or "American Cancer Society" sponsor. We tested the effect of varying sponsorship on source attribution and source credibility. RESULTS: Compared to unsponsored labels, FDA sponsorship increased source attributions that the FDA sponsored the labels among both middle-school, largely nonsmoking youth and adult smokers. However, sponsorship had no effect on source credibility among either population. CONCLUSIONS: We found no evidence that adding FDA as the source is likely to boost source credibility judgments, at least in the short term; though doing so would not appear to have adverse effects on credibility judgments. As such, our data are largely consistent with the Tobacco Control Act's provisions that allow, but do not require, FDA sponsorship on the labels. IMPLICATIONS: This study addresses the FDA's regulatory efforts by informing the possible design and content of future cigarette warning labels. Our results do not offer compelling evidence that adding the FDA name on GWLs will directly increase source credibility. Future work may test more explicit FDA source labeling and continue to examine the credibility of tobacco message content among high-priority populations.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups.

INTRODUCTION: The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use. METHODS: We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes. RESULTS: Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions. CONCLUSIONS: We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products. IMPLICATIONS: This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.