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Background: Pictorial warnings may contribute to lower attractiveness of smoking, particularly among adolescents. The present study compared the impact of two different label styles of tobacco product warnings (textual and pictorial) among adolescents in a new standardized way, using the Adolescent Label Impact Index (ALII). Methods: A school-based cross-sectional study was conducted. Adolescent aged 10-20 years completed an online questionnaire. The ALII score was used to assess the impact of only-textual (ALII-T) and pictorial advertisements (ALII-P). Results: A total of 1,759 students (68.4% response-rate) declared that graphic warnings have a significant impact than textual ones (p < 0.05). The younger group, which has never smoked or just tried and believed in the harmful effects of tobacco, is associated with both scales of ALII scales (T and P) (p < 0.01). The socioeconomic status was associated with ALIIT (p < 0.01), but not ALII-P; female gender, smoker-peers, perception of the body weight are related to the ALII-P (p < 0.05) but not ALII-T. Conclusions: The pictorial labels represent a policy of tobacco use control that has potential effects, in particular in reducing communication inequalities between socio-economic categories, reinforcing the knowledge about the damage of smoking, discouraging adolescents, especially the younger ones who do not have never smoked or have just tried to become smokers. [This article was co-written by Collaborative Group including: Siriana Campioni, Armando Platania, Ilenia Bellini, Omar Enzo Santangelo, and Clara Ferrara.]

Pictorial warnings may contribute to lower attractiveness of smoking, particularly among adolescents. The present study compared the impact of two different label styles of tobacco product warnings (textual and pictorial) among adolescents in a new standardized way, using the Adolescent Label Impact Index (ALII). A school-based cross-sectional study was conducted. Adolescent aged 10–20 years completed an online questionnaire. The ALII score was used to assess the impact of only-textual (ALII-T) and pictorial advertisements (ALII-P). A total of 1,759 students (68.4% response-rate) declared that graphic warnings have a significant impact than textual ones (p < 0.05). The younger group, which has never smoked or just tried and believed in the harmful effects of tobacco, is associated with both scales of ALII scales (T and P) (p < 0.01). The socioeconomic status was associated with ALII-T (p < 0.01), but not ALII-P; female gender, smoker-peers, perception of the body weight are related to the ALII-P (p < 0.05) but not ALII-T. The pictorial labels represent a policy of tobacco use control that has potential effects, in particular in reducing communication inequalities between socio-economic categories, reinforcing the knowledge about the damage of smoking, discouraging adolescents, especially the younger ones who do not have never smoked or have just tried to become smokers. Siriana Campioni, Department of Public Health and Infectious Disease, "Sapienza" University of Rome Gabriele Castorina, Armando Platania, Specialization School of Hygiene and Preventive Medicine, Department "GF Ingrassia" Hygiene and Public Health, University of Catania, Italy; Ilenia Bellini, School of Specialization in Hygiene and Preventive Medicine, University of Florence Omar Enzo Santangelo, Specialization School of Hygiene and Preventive Medicine, Department of Sciences for Health Promotion and Mother and Child Care "Giuseppe D'Alessandro," University of Palermo Clara Ferrara, Department of Gynecology and Obstetrics Palermo Civic Hospital and National Center of Clinical Excellence (ARNAS Di Cristina-Benfratelli) Palermo, Italy. [ABSTRACT FROM AUTHOR]