Abstract Pictorial warnings on cigarette packs motivate smokers to quit, and yet the warnings’ theoretical mechanisms are not clearly understood. To clarify the role that risk appraisals play in pictorial warnings’ impacts, we conducted a meta-analysis of the experimental literature. We meta-analyzed 57 studies, conducted in 13 countries, with a cumulative N of 42,854. Pictorial warnings elicited greater cognitive elaboration (e.g., thinking about the risks of smoking; d = 1.27; p < .001) than text-only warnings. Pictorial warnings also elicited more fear and other negative affect (d = .60; p < .001). In contrast, pictorial warnings had no impact on perceived likelihood of harm (d = .03; p = .064), perceived severity (d = .16; p = .244), or experiential risk (d = .06; p = .449). Thus, while pictorial warnings increase affective and some cognitive risk appraisals, they do not increase beliefs about disease risk. We discuss the role of negative affect in warning effectiveness and the implications for image selection and warning implementation.