Discussion
In this study, the majority of participants were young adults, revealing a notable sex disparity between smokers and non-smokers, with males predominantly represented among smokers and females among non-smokers. These trends mirrored those observed in national data from the Malaysia Global Adult Tobacco Survey (GATS), 2011 ( Institute of Public Health (IPH), 2012b ). Remarkably, both smokers and non-smokers exhibited a propensity toward tertiary education, a contrast from the conventional association between lower educational attainment and smoking in Malaysia, as highlighted in the National Health and Morbidity Survey (NHMS), 2019 ( Institute for Public Health (IPH), 2019 ). Interestingly, the NHMS found a lower prevalence of cigarette smoking among respondents with tertiary education ( n = 2,426, 21.9%) compared to those with primary ( n = 2,540, 23.0%) and secondary education ( n = 5,442, 49.2%) levels, challenging the notion that educational level is a reliable indicator of smoking behaviour ( Institute for Public Health (IPH), 2019 ; Mohd Yusoff et al., 2022 ). Consequently, while gender-related data may offer insights applicable to the broader population, caution is warranted in generalising findings based solely on educational demographics.

The majority of smokers in this study disclosed a habit of daily smoking, closely followed by those who smoked infrequently. This aligns with findings from the Global Adult Tobacco Survey (GATS) 2011, which indicated that a significant proportion of current tobacco users reported daily smoking (20.9%, 95% CI [19.0–22.9]) compared to occasional smoking (2.3%, 95% CI [1.7–3.0]) ( Institute of Public Health (IPH), 2012a ). Furthermore, the study revealed that most smokers had initiated smoking within the past 5 years, with only a tiny fraction having smoked for over a decade. This contradicts past studies by Rahman et al. (2022) and Williams et al. (2021) , having said that most smokers (72.9% and 80.6%) had smoked for more than 10 years. Additionally, the data indicated that the majority of participants smoked fewer than ten cigarettes per day, while a minority smoked more heavily, which was more than 20 cigarettes daily. This suggests a prevalence of light smoking among respondents, consistent with GATS 2011, which similarly identified a low proportion of heavy smokers exceeding 25 cigarettes per day (8.1%) ( Institute of Public Health (IPH), 2012b ).

Overall, non-smokers exhibited a significantly higher level of interaction with the pictorial warnings on cigarette packaging (label processing), including reading, thinking about, and discussing them, compared to smokers. This finding is consistent with a study by Ratneswaran et al. (2016) , which observed that non-smokers engaged in more discussions about pictorial warnings than smokers. These results suggest that non-smokers perceive pictorial warnings as more significant than smokers. This assertion is further supported by research conducted in Laos by Sychareun et al. (2015) , which found that non-smokers were more inclined to rate pictorial warnings as very important than smokers (69.1% vs . 59.8%).

In this research, non-smokers exhibited a greater level of awareness regarding the health consequences of tobacco use compared to smokers. However, both groups displayed significant knowledge regarding the health effects depicted on cigarette packs through pictorial warnings. The highest percentages of awareness were observed regarding the association between tobacco smoking and lung cancer, indicating that a majority of respondents recognised this correlation. This aligns with findings from a study by Rahman et al. (2015) conducted in Sarawak, where respondents acknowledged smoking as a cause of lung cancer. This heightened awareness may be attributed to the widespread public health campaigns highlighting the link between smoking and lung cancer.

Additionally, mouth cancer emerged as another well-recognised health consequence of tobacco smoking. Other studies have similarly found pictorial warnings depicting lung, mouth, and neck cancer among the most recognisable health warnings ( Hamzah, Saub & Marhazlinda, 2021 ). However, awareness regarding other health consequences, such as gangrene, was notably lower. This discrepancy could potentially be attributed to a lack of education regarding the medical connection between smoking and these specific health warnings, particularly in the case of pregnancy-related images and gangrene.

In this study, it is revealed that individuals who do not smoke demonstrate heightened emotional reactions toward pictorial warnings in comparison to smokers across three distinct metrics: fear, disgust, and avoidance of viewing the images. This aligns with research conducted by Gantiva et al. (2022) , which indicated that pictorial warnings are more impactful for non-smokers than smokers. The findings suggest that smokers may develop desensitisation to pictorial warnings due to repeated exposure to cigarette packaging, potentially diminishing the effectiveness of such warnings over time, as smokers are accustomed to them. Ratneswaran et al. (2016) similarly observed that pictorial warnings are more efficacious for non-smokers, attributing this discrepancy to smokers’ existing awareness of the hazards associated with smoking. Additionally, a more significant proportion of non-smokers reported experiencing heightened feelings of ‘fear’ and ‘disgust’ compared to smokers ( Ratneswaran et al., 2016 ). The habitual exposure of smokers to cigarettes and health warnings may attenuate the impact of pictorial warnings, indicating that smokers might also manifest emotions such as denial or dismissal in response to these warnings.

Our research indicates that a significant portion of smokers perceive pictorial warnings as influential in prompting them to contemplate quitting tobacco usage. Specifically, our findings reveal that smokers frequently entertain thoughts of reducing cigarette consumption. This observation is consistent with past studies conducted in the United States, Spain, and France by Andrews et al. (2016) , which underscored the efficacy of pictorial warnings in facilitating smoking cessation among smokers. Correspondingly, a survey conducted by Sychareun et al. (2015) found that most smokers expressed that pictorial health warnings were motivating factors to reconsider their tobacco habits. Furthermore, Fathelrahman et al. (2010) demonstrated that most smokers occasionally pondered the idea of quitting smoking upon encountering pictorial warnings and reflected on the associated health risks. Our study underscores the emotional impact of pictorial warnings, prompting contemplative thoughts such as considerations of quitting smoking, reducing cigarette consumption, and contemplating health risks. However, it is noteworthy that these warnings do not consistently deter smokers from continuing their smoking habit. Previous research by Pepper et al. (2020) suggests that some smokers may actively avoid looking at these warnings, potentially diminishing their immediate impact. Our findings suggest that many smokers are in a contemplation stage, acknowledging the issue but needing more readiness and confidence to enact behavioural changes regarding their smoking habits, thus not progressing beyond contemplation into action.

The impact of pictorial warnings on smoking initiation has predominantly been examined in non-smokers, focusing on their perceived impact on the inclination to smoke following exposure to such warnings. Previous research conducted by Auemaneekul et al. (2015) suggests that pictorial warnings play a significant role in dissuading non-smokers from initiating smoking. Auemaneekul et al. (2015) compared the effects of pictorial warnings and plain packaging, revealing a heightened intention not to smoke among non-smokers and former smokers after exposure to plain packaging compared to current smokers. Our findings align with this trend, indicating that a majority of non-smokers reported never experiencing an urge to smoke upon encountering pictorial warnings. This underscores the heightened awareness among non-smokers regarding the health risks associated with smoking, as facilitated by their comprehension of the dangers and consequences depicted in the warnings. Consequently, non-smokers may exhibit reduced susceptibility to the temptation of smoking, as the graphic imagery fosters a negative association with tobacco use, thereby diminishing its appeal among this demographic.

Our investigation into the most impactful images on cigarette packs reveals disparate responses from smokers and non-smokers towards pictorial warnings. Smokers identified lung cancer as the most impactful image, while non-smokers cited mouth cancer. This finding resonates with prior research by Hamzah, Saub & Marhazlinda (2021) , indicating that pictorial health warnings concerning lung, neck, and oral health are most comprehensible and accepted by respondents. Additionally, Gantiva et al. (2022) , found that images depicting cancers and abortion evoke more excellent emotional responses compared to others. Interestingly, our study found that respondents deemed gangrene as the least impactful image, suggesting a lack of awareness regarding this medical condition associated with smoking-related health risks. Hamzah, Saub & Marhazlinda (2021) emphasise the importance of crafting comprehensible messages in pictorial warnings, particularly avoiding medical terminology such as ‘gangrene’ and focusing on easily understood language accessible to individuals with diverse educational backgrounds and cultural perspectives. Therefore, providing explanatory notes alongside health warning labels could enhance understanding. Our findings underscore the necessity of integrating insights from health professionals and considering the knowledge levels of target audiences during the development of pictorial warning labels.

From a policy perspective, these findings highlight the need to evaluate and enhance continuously. Although pictorial warnings have proven effective in raising awareness, especially among non-smokers, their limited impact on smoking cessation among smokers suggests that additional interventions are necessary. Policymakers should consider adopting more aggressive tobacco control strategies, such as increasing the size of pictorial warnings on cigarette packaging or implementing plain packaging, which has been shown to reduce the appeal of tobacco products, especially among young adults and new smokers. Public health campaigns targeting specific demographics, such as males and lower-educated populations, should be intensified to close the gaps in awareness and smoking behaviour. Furthermore, policies encouraging frequent rotation of warning images and incorporating culturally relevant messages could enhance their effectiveness.

Future research should explore more personalised and dynamic approaches to messaging. Studies could investigate whether rotating more graphic and emotionally charged images could mitigate the desensitisation observed among smokers over time. In addition, research should assess the potential benefits of combining pictorial warnings with other cessation aids, such as counselling services or digital interventions, which could help move smokers from contemplation to action. Longitudinal studies tracking smoking behaviour over extended periods would also provide valuable insights into the long-term effects of pictorial warnings on smoking cessation, particularly in light of changing trends in tobacco use and public health messaging.

Finally, future investigations should explore the psychological mechanisms behind why specific images (such as lung or mouth cancer) resonate more with different groups. Understanding these emotional triggers can inform the design of more targeted and impactful warnings. Researchers should also look into the role of socioeconomic and cultural factors in shaping responses to pictorial warnings, ensuring that future tobacco control policies are inclusive and resonate with diverse population groups.

By addressing these areas through policy enhancements and targeted research, there is potential to significantly strengthen the effectiveness of pictorial warnings in both preventing smoking initiation and promoting smoking cessation.

The key limitation of this study is that the utilisation of a cross-sectional structured survey presents another challenge, as respondents may be inclined to provide socially desirable responses, particularly regarding sensitive topics like smoking. This bias could lead to underreporting of smoking or overreporting of intentions to quit among smokers. At the same time, non-smokers may hesitate to admit any inclination towards starting smoking due to fear of judgment.