Emotional arousal of graphic cigarette warning labels loses its beneficial effects on craving reduction after repeated exposure – A longitudinal neuroimaging study

Graphic warning labels (GWLs) on cigarette packaging have been implemented in many countries. In the U.S., however, GWLs have faced legal challenges based on concerns that their aversive imagery elicits excessive emotional arousal without sufficient data to support its beneficial impact. This longitudinal study examined how GWLs’ level of arousal affects cigarette craving and neural responses related to emotional processing. A total of 158 adults who smoked cigarettes were exposed to either high-arousal (n=79) or low-arousal (n=79) GWLs attached to their cigarette packs for 4 weeks. Cigarette craving and brain responses to GWLs were measured using functional magnetic resonance imaging before and after the exposure period. The amygdala, a key region involved in emotional processing, was the brain region of interest. At baseline, high-arousal GWLs elicited a greater reduction in craving and stronger amygdala activation than low-arousal GWLs. However, by week 4, the differences in craving reduction and amygdala response between groups were no longer significant. Amygdala activity mediated the effect of GWLs on craving reduction, with the mediation effect being more pronounced in the high-arousal group than the low-arousal group at baseline but not at week 4. The impact of GWL-induced arousal on cigarette craving appears to diminish over time, likely due to habituation in amygdala reactivity. High-arousal GWLs do not provide sustained advantages over low-arousal ones. Low-arousal GWLs may represent a more practical and legally defensible approach to tobacco control in the U.S. • We tested the effects of cigarette GWLs evoking high vs. low emotional arousal. • High-arousal GWLs initially activated amygdala and reduced craving more strongly. • Differences between high- and low-arousal GWLs disappeared after 4-week exposure. • Amygdala habituation may underlie the diminishing effect of arousal over time. • High-arousal imagery in GWLs may not offer long-term benefits.