Objectives This study aimed to evaluate Japanese smokers' perceptions of health warnings on tobacco packaging by comparing text-only and pictorial warnings.Methods Data were sourced from the Japan Society and New Tobacco Internet Survey (JASTIS), an online, self-reported study conducted in February and March 2020. Participants included current smokers aged 15-74 years in Japan (n＝2,372). Perceptions regarding five packaging samples were assessed: the old package (text-only warning covering 30% of the pack's front and back before April 2020), the current package (text-only warning covering 50% of the pack's front and back), and three packages with pictorial warnings covering 50% of the front and back. Respondents were asked four questions on a 5-point Likert scale regarding the effectiveness of these warnings in terms of discouraging young people from starting to smoke, encouraging them to quit, communicating the dangers of smoking, and comfort level with the warnings. A t-test was conducted to compare each pair of packages.Results There were no significant differences observed between the "text only 30%" and "text only 50%" packages in terms of preventing young individuals from starting to smoke, encouraging quitting, or communicating the dangers of smoking (P＝0.740-0.987). Conversely, packages with pictorial warnings were perceived as more effective than text-only packages (P＜0.01) in all aspects. A significant difference was observed in the respondents' perceptions of comfort levels with the packages, with the pictorial ones deemed more uncomfortable (P＜0.01).Conclusion The findings indicated that pictorial health warnings are significantly associated with increased awareness of smoking risks, motivation to quit smoking, and prevention of smoking initiation among young people. Accordingly, Japan should consider adopting pictorial health warnings in accordance with the Framework Convention on Tobacco Control.
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