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Background Many studies have shown that pictorial health warnings (PHWs) are more effective in increasing knowledge about the many harms of cigarettes. Zambia currently has a single text-only English warning covering less than 3% of pack. This study is the first to assess health knowledge and the effectiveness of warnings in Zambia. Methods Data were from 1,171 smokers in the International Tobacco Control (ITC) Zambia Wave 2 Survey (2014), a longitudinal survey of a nationally representative sample of Zambian adults. Key variables analyzed were knowledge of specific harms of smoking and validated indicators of warning effectiveness. Results Knowledge among Zambian smokers was very low compared to other ITC countries: only 45% knew that smoking causes stroke (2 nd lowest among 20 ITC countries), heart disease (74%--3 rd lowest among 14 ITC countries), and lung cancer (79%--lowest among 12 ITC countries). The Zambian text-only warning was very ineffective: 58% of Zambian smokers reported “never” or “hardly ever” noticing the warning; only 24% reported closely reading the warning. 75% reported that warning “never” stopped them from smoking; 70% reported that warning did not make them more likely to think about health risks; 66% reported that warning “never” made them think about quitting. When shown the warning, 55% of smokers were not able to easily read it. And yet 71% thought the packs should have more health information and 86% wanted the government to do more about harms of tobacco use. Conclusions Knowledge of tobacco-related harms is very poor among Zambian smokers and the single-text only warning provides no help, particularly among the many low literacy smokers in Zambia. There is a clear need for Zambia to implement pictorial health warnings, as they are obligated to do as a Party to the FCTC and as other African countries - Mauritius and Kenya - have already done successfully.