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Speaking out about physical harms from tobacco use: response to graphic warning labels among American Indian/Alaska Native communities
  1. David A Patterson Silver Wolf, (Adelv unegv Waya)1,
  2. Molly Tovar2,
  3. Kellie Thompson1,
  4. Jamie Ishcomer2,
  5. Matthew W Kreuter3,
  6. Charlene Caburnay3,
  7. Sonia Boyum3
  1. 1Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
  2. 2Kathryn M Buder Center for American Indian Studies, Washington University in St. Louis, St. Louis, Missouri, USA
  3. 3Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, Missouri, USA
  1. Correspondence to Dr David A Patterson-Silver Wolf (AdelvunegvWaya); dpatterson22{at}


Objective This study is the first to explore the impact of graphic cigarette labels with physical harm images on members of American Indian/Alaska Native (AI/AN) communities. The aim of this article is to investigate how AI/AN respond to particular graphic warning labels.

Methods The parent study recruited smokers, at-risk smokers and non-smokers from three different age groups (youths aged 13–17 years, young adults aged 18–24 years and adults aged 25+ years) and five population subgroups with high smoking prevalence or smoking risk. Using nine graphic labels, this study collected participant data in the field via an iPad-administered survey and card sorting of graphic warning labels. This paper reports on findings for AI/AN participants.

Results After viewing graphic warning labels, participants rated their likelihood of talking about smoking risks to friends, parents and siblings higher than their likelihood of talking to teachers and doctors. Further, this study found that certain labels (eg, the label of the toddler in the smoke cloud) made them think about their friends and family who smoke.

Conclusions Given the influence of community social networks on health beliefs and attitudes, health communication using graphic warning labels could effect change in the smoking habits of AI/AN community members. Study findings suggest that graphic labels could serve as stimuli for conversations about the risks of smoking among AI/AN community members, and could be an important element of a peer-to-peer smoking cessation effort.

  • American Indian/Alaska Native
  • graphic warning labels
  • tobacco use

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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