Introduction
In 2019, smoking claimed the lives of 7.69 million individuals globally ( GBD 2019 Tobacco Collaborators, 2021 ), resulting in one death every 4 seconds due to smoking-related illnesses. Consequently, tobacco smoking stands out as one of the leading causes of mortality worldwide. It is associated with various health complications, including lung cancer, heart disease, stroke, and chronic obstructive pulmonary disease (COPD) ( World Health Organization (WHO), 2023 ). In Malaysia alone, smoking is responsible for approximately 20,000 deaths annually ( Lim et al., 2022 ). Conversely, cigarette smoking has declined, dropping from 33.3% in 2000 to a targeted prevalence of 20.9% in 2025 ( World Health Organization (WHO), 2013 ). This decline is likely attributable to a range of tobacco prevention initiatives, efforts to promote smoking cessation, and heightened public awareness regarding the adverse effects of smoking and exposure to secondhand smoke ( Levy, Li & Yuan, 2019 ). Promoting smoking cessation is among the strategies aimed at assisting smokers in quitting or reducing their cigarette consumption by increasing the frequency of smoking cessation attempts to reduce the morbidity and mortality associated with cigarette use ( World Health Organization (WHO), 2013 ; Levy, Li & Yuan, 2019 ; Hughes, 2003 ).

Pictorial health warnings on tobacco products have proven effective in informing consumers about the harmful effects of tobacco use, as stipulated in Article 11 of the Framework Convention on Tobacco Control (FCTC) by the World Health Organization (WHO) (2021) . Compared to text-only health warnings, pictorial warnings on cigarette packages are more likely to capture attention, educate individuals about health risks, elicit more robust emotional responses, and motivate smokers to quit or reduce their tobacco consumption ( Cornacchione Ross et al., 2023 ). Specific strategies outlined in the guidelines include placing pictorial warnings on the front and back of the packaging in undamaged areas upon opening, ensuring the display size covers 30 to 50 per cent or more of the main display area with prominently bold health messages, utilising culturally appropriate images, employing contrasting colours, and rotating pictorials. These guidelines are designed to enhance visibility and optimise the effectiveness of conveyed messages ( World Health Organization (WHO), 2021 ).

Countries such as Brazil, Thailand, Singapore, Hong Kong, Chile, Australia and Canada that adopted pictorial warnings experienced a reduction in cigarette consumption due to increased exposure to these warnings and enhanced health awareness ( Rekha & Anjum, 2012 ). In Malaysia, the introduction of pictorial warnings was facilitated by enacting the Control of Tobacco Product (Amendment) Regulations (CTPR) in 2008. Effective January 1, 2009, cigarette packs sold in Malaysia became compulsory to feature six rotating pictorial warnings covering 40% of the front and 60% of the back of the main areas of each pack ( Ministry of health Malaysia, 2008 ).

A specific study conducted a comprehensive review of available literature concerning the perceived impact of pictorial health warnings on smoking behaviour changes across various Asian countries, encompassing Malaysia, China, Pakistan, Jordan, Thailand, India, Bangladesh, Turkey, Qatar, Laos, and Indonesia ( Ratih & Susanna, 2018 ). They concluded that pictorial health warnings are perceived as more effective in preventing smoking initiation among non-smokers and in encouraging smoking cessation among smokers ( Ratih & Susanna, 2018 ). While local researchers have investigated the efficacy and effectiveness of pictorial warnings in enhancing tobacco awareness among adult smokers in Malaysia, particularly regarding their intent to quit ( Institute of Public Health (IPH), 2012a ), there is still a lack of research exploring the comparison between smokers and non-smokers to gain deeper insights, as well as examining the long-term effects of pictorial warnings on smoking behaviour in the Malaysian context.

Pictorial warnings represent a distinctive aspect of tobacco control initiatives as they are encountered directly during smoking. This means nearly every smoker is exposed to these warnings, with pack-a-day smokers encountering them over 7,000 times annually ( Hammond et al., 2003 ). Due to this extensive reach and frequency of exposure, even if the impact of pictorial warnings on individual smokers is modest, they hold the potential to exert a substantial influence on smoking behaviour at the population level ( Hammond et al., 2003 ).

The ongoing discussion regarding the enduring impact of pictorial warnings on cigarette packaging in reducing smoking rates prompts further investigation. Thus, the primary objective is to examine the perception and effects of pictorial warnings on smokers and non-smokers, including their smoking behaviour. The secondary objective involves comparing the perceptions of smokers and non-smokers regarding pictorial warnings on cigarette packaging and assessing the effectiveness of specific images used on pictorial warnings.