Results
Three hundred and seventy-eight respondents participated in this study. The demographic data for the participants are summarised in Table 1 . Most respondents ( n = 223, 58.9%) were between the ages of 20–29. More smokers were male ( n = 172, 91%) than non-smokers, who were primarily female ( n = 119, 63%). Most respondents ( n = 207, 54.7%) had tertiary education. There is a statistically significant difference ( p -value < 0.001) found between respondents’ smoking status, gender, and education level.

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Table 2 describes the tobacco usage of smokers. One hundred and eighty-nine participants who were smokers were assessed for their tobacco use. A majority of the smokers ( n = 105, 27.8%) reported smoking every day, followed by 60 (15.9%) who seldom smoked. Only 24 (6.3%) reported smoking at least once a week. Most smokers ( n = 81, 42.9%) reported using tobacco for less than 5 years, least smokers ( n = 40, 10.6%) smoked more than 10 years. Another 40 (18%) smoked between 5 to 10 years. Most of the smokers ( n = 109, 28.8%) reported smoking less than ten cigarettes per day, and only 13 (3.4%) smoked more than 20 cigarettes per day.

Table 3 shows the respondents’ perception towards pictorial warnings on cigarette packaging. Most respondents ( n = 374, 96.3%) noticed the pictorial warnings on cigarette packaging. Hence, statistically significant differences were not found between smokers and non-smokers ( p -value = 0.276). A statistically significant difference was found between smokers and non-smokers in the frequency of reading pictorial warnings ( p -value < 0.001). Most smokers ( n = 73, 38.6%) rarely read pictorial warnings compared to non-smokers ( n = 57, 30.2%). Most non-smokers ( n = 69, 36.5%) sometimes read pictorial warnings compared to smokers ( n = 44, 23.3%). Most smokers ( n = 61, 32.3%) think about pictorial warnings compared to non-smokers ( n = 51. 27.0%). While most non-smokers ( n = 56, 29.6%) sometimes think about the pictorial warnings. Next, most smokers ( n = 82, 43.4%) never discussed the pictorial warnings with their peers as opposed to non-smokers ( n = 41, 21.7%). Meanwhile, most non-smokers ( n = 59, 31.2%) sometimes discussed with peers compared to smokers ( n = 42, 22.2%). A statistically significant difference was noted in the frequency of discussing pictorial warnings between smokers and non-smokers ( p -value < 0.001). Lastly, most smokers ( n = 71, 37.6%) never thought about pictorial warnings when they were not in sight compared to non-smokers ( n = 37, 19.6%). Meanwhile, most non-smokers ( n = 56.6%) sometimes thought about the pictorial warnings when not in sight as opposed to smokers ( n = 43, 22.8%). Similarly, a statistically significant difference was found in the frequency of thinking about pictorial warnings when not in sight between smokers and non-smokers ( p -value < 0.001).

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Figure 2 describes the known health effects of tobacco use among respondents. The two most recognised health effects of smoking by both groups of respondents are lung cancer ( p -value = 0.011) and mouth cancer ( p -value < 0.001), with 170 (89.9%) smokers and 184 (97.4%) non-smokers who answered ‘Yes’ for lung cancer while 152 (80.4%) smokers and 181 (95.8%) non-smokers answered ‘Yes’ for mouth cancer. Following these were premature birth ( p -value < 0.001), with 156 (82.5%) smokers and 176 (93.1%), miscarriages ( p -value = 0.048), with 149 (78.8%) smokers and 164 (86.8%) non-smokers, neck cancer ( p -value < 0.001) with 144 (76.2%) smokers and 165 (87.3%) non-smokers and lastly gangrene ( p -value < 0.001) with 115 (60.8%) smokers and 139 (73.5%) who answered ‘Yes’ for respective health effects.

The emotional impact of pictorial warnings, which include fear, disgust, and avoiding looking into the image for smokers and non-smokers, were assessed respectively ( Table 4 ). A statistically significant difference ( p -value < 0.001) can be seen between smokers’ and non-smokers’ emotional responses to ‘fear’, ‘disgust’, and ‘avoiding looking into the pictorial images of cigarette packaging’. Non-smokers (7.61 ± 2.170) showed a higher fear level than smokers (4.08 ± 2.621). Alongside the other emotional impact, non-smokers (7.75 ± 2.219) felt more disgusted towards the sight of the pictorial images compared to smokers (4.14 ± 2.774). Non-smokers (6.31 ± 2.762) tend to avoid looking into the pictorial images higher than smokers (4.04 ± 2.904).

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One hundred and eighty-nine smokers were assessed on the impact of pictorial warnings on quitting smoking ( Table 5 ). Table 5 shows that smokers sometimes ( n = 48, 25.4%) and rarely ( n = 47, 24.9%) considered quitting smoking upon the sight of pictorial warnings on cigarette packs. Most ( n = 53, 28.0%) frequently consider quitting smoking upon looking at the pictorial warning. Smokers sometimes ( n = 53, 28.0%) consider reducing the use of cigarettes, while 40 smokers never and rarely (21.2%) consider decreasing tobacco use. Most smokers ( n = 56, 29.6%) frequently consider reducing cigarette use upon the sight of pictorial warnings. The target group sometimes ( n = 64, 33.9%) had thoughts about health risks regarding tobacco use upon seeing the pictorial warnings. In contrast, some smokers ( n = 24, 12.7%) never considered the risk to health concerning the impact of pictorial warnings. Smokers mostly admit that the pictorial warnings never ( n = 77, 40.7%) refrained themselves from smoking. Only 16.9% ( n = 32) of smokers agree that the pictorial warning frequently refrains them from smoking.

Figure 3 shows the impact of pictorial warnings on the initiation of smoking by non-smokers. Most non-smokers ( n = 161, 85.2%) never had the urge to smoke upon the sight of pictorial warnings on the cigarette packaging. It follows that 12 out of 189 rarely and sometimes (6.3%) had the urge to smoke, respectively. However, a small number of respondents frequently ( n = 4, 2.1%) had the urge to smoke about the impact of pictorial warnings.

Table 6 describes the most impactful image on cigarette packs by respondents. There is a statistically significant difference ( p -value < 0.05) between smokers and non-smokers on impactful images on cigarette packs among respondents. The majority of smokers chose lung cancer ( n = 74, 39.2%) as the most impactful image on cigarette packs, followed by premature birth ( n = 41, 21.7%), neck cancer ( n = 39, 20.6%), miscarriage ( n = 10, 5.3%) and lastly gangrene ( n = 6, 3.2%). However, non-smokers picked mouth cancer ( n = 59, 31.2%) as the most impactful pictorial warnings on cigarette packs, subsequently lung cancer ( n = 58, 30.7%), neck cancer ( n = 45, 23.8%), premature birth ( n = 15, 7.9%), and lastly gangrene ( n = 5, 2.6%).

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