Tobacco health warnings do benefit smokers!

Manjari Peiris

The theme for World No Tobacco Day this year (May 31) was Tobacco Health Warnings.

On this day and the years to follow the World Health Organization will encourage governments to adopt tobacco health warnings meeting all the criteria for maximum effectiveness covering more than half of the pack to appear on both the front and the back of the pack along with pictorial warnings. They will be among the strongest defences against the global epidemic of tobacco.

The WHO Framework Convention on Tobacco Control obligates its more than 160 countries parties to require “health warnings describing the harmful effects of tobacco use” on packs of tobacco and their outside packaging and recommends that the warnings contain pictures.

WHO works through its Tobacco Free Initiative department to help the parties to meet their obligation, providing technical and other assistance.

There are an estimated 1.2 billion regular smokers in the world today; approximately one third of the global population over the age of 15, and the numbers are rising. Studies show that many smokers still do not know that tobacco causes disease and premature death.

Therefore there is a clear need for effective ways to inform and alert smokers and provide information on how to reduce their tobacco-related health risks. Strongly worded, specific, large label information along with pictorial warnings on tobacco product packages provides important public health messages, targeting smokers.

Mandated labels on tobacco products are an effective way to inform smokers of the hazards of smoking, encourage smokers to quit, and discourage nonsmokers from starting to smoke.

Many countries require health warnings on tobacco products. Evaluations of these warnings conclude that they are effective only if they contain multiple strong and direct messages that are prominently displayed along with pictorial warnings.

Evidence from Canada and Brazil shows that the large warnings with photos introduced recently are effective in discouraging smoking and increasing public awareness of the health effects of smoking.

Of 633 Canadian smokers surveyed nine months after new, large pictorial warnings were introduced, 58% said the pictures had made them think more about the health effects of smoking; 44% said the new warnings increased their motivation to quit smoking; and 38% of smokers who tried to quit in 2001 said the new warnings were a factor in motivating their attempt.

In a survey of 2,216 Brazilians 18 years or older in 126 municipalities, in April 2002, 3 months after the introduction of new picture warnings, 73% of smokers approved of them, 54% had changed their opinion on the health consequences of smoking and 67% said that the new health warnings made them want to quit.

The impact was especially strong among people with low incomes and education. In Australia, stronger warning labels resulted in a 29% increase in the percentage of people reporting that they always noticed the warnings, and a 7% increase in people reporting forgoing smoking at least once due to the warnings. Other studies report similar findings.

Package warning efficiently target smokers

A survey of 8,836 people 15 and older in the Netherlands in 2002 found that 16% of the 2,812 smokers surveyed said that new, larger health warnings made them more motivated to quit, (this was 26% among smokers who intend to quit at some point); 8.7% said they were already smoking less as a result of the new warnings. Surveys find that a high proportion of smokers (for example, 70% in Canada) want to quit.

Strong health warnings and information about where to turn for help in quitting help reinforce this attitude.

Smokers (and potential smokers) see the warnings at points of purchase and every time they take a cigarette, or handle or see a cigarette pack. Targeting smokers is especially important in developing countries where a few people have access to information about the hazards of smoking.

Large health warnings detract from the glamour and appeal of tobacco packages, making them less likely to be seen as stylish accessories. Strong warnings also help to create a social milieu in which non-smoking is the norm. They can inform smokers who want to quit about where to find help.

Legal and ethical considerations

‘Informed consent’ or consumer protection laws in some countries require that information is provided to smokers about the health effects of tobacco use. In Canadian law, “informed consent is held to exist when June 2003 adult buyers are informed about: the nature of the risks (for example, that smoking causes lung cancer and a host of other potentially fatal diseases); the magnitude of the dangers including the prognosis should illness develop (for instance, that lung cancer has a very high fatality rate); and the probability of such diseases occurring”.

Common law requires that “once a duty to warn is recognized, the warning should be communicated clearly and understandably, and in terms commensurate with the gravity of the potential hazard”

Country experiences

Canada and Brazil have become global leaders, and now require large tobacco package warning labels, with pictures and strong text. In Canada the top half of the front and back of cigarette packages must show one of 16 picture-based warnings. One of 16 additional detailed messages is required inside the package, either on an insert or on the inner “sliding” part of the package.

Brazil introduced similar warnings in 2002, and has banned the use of misleading terms such as “Light”, “Ultra-light”, “Slim”, and “Super slim” on cigarette packages. Picture-based warnings are being considered in Australia and Thailand, and a European Community directive gives member states the option of using them.

But warnings are weak, small or non-existent in many other parts of the world, especially in developing countries.

More than 40 developing countries do not have any warnings at all. A review of regulations on the content, size, and location of tobacco health warnings in 45 countries found that people in developing countries receive inferior information about the hazards of smoking.

This is unacceptable, especially since about 80% of the world’s smokers live in developing countries. Effective tobacco pack labels Detailed specifications on all aspects should be included in legislation or regulations governing the information required on tobacco packs, to prevent companies making them difficult to read or weak.

* Size: the warning/information label should ideally cover 50% of the front and back areas of the package. Warnings must be large enough to be easily noticed and read. Evidence suggests that the perceived credibility of warning messages, as well as the perceived risks from tobacco use, increase proportionately with increases in the size of warnings.

Content

To be effective, warnings have to contain a clear and unequivocal message about the dangers of tobacco use, in simple and stark terms. Messages should be worded simply and be in the principal language(s) of the country.

They should explain the nature and extent of risk, and what to do to avoid or reduce the risks. They should speak directly to the reader using the word “you.” Technical language should be avoided.

The use of marker words, such as “WARNING” is desirable. The message should not be diluted by attribution to government agencies or officials. (However, in Canada, the court ruled that warnings must be attributed to the government, lest they be seen as statements by the cigarette companies themselves, who have a constitutional right to free speech, interpreted to include the right to not say something.)

It is important to include information about where to find cessation help: for example, a toll-free quit line number (as in Australia, Brazil, the EC, Canada and South Africa), an Internet and/or physical address where more information is available, quitting tips, and/or advice to ask a health care provider for help in quitting.

Packages should be free of erroneous or misleading terms, such as “light”, “low tar”, or “mild”, which give the wrong impression that tobacco is safer at lower tar and/or nicotine concentrations.

These misleading terms have been banned in Brazil and the European Union, and several other countries are considering banning them.

Format and font: the warning message should be printed in easy-to-read black type on a white background (or vice versa). Large upper case letters should be used.

Glossy surface coatings and metallic inks should be avoided; flat or matte finish will make the warnings legible under a wider range of lighting conditions. The text should be indelible and irremovably fixed. A black border should surround the message in a way that does not interfere with the text of the warning or the information given.

Location: the warnings should be on the top of the front and back of the package. The warning should not be hidden or obscured by other written or pictorial matter, or when the packet is open.

Pictures: warning messages with pictures are accessible to illiterate people, and provide significantly more encouragement to quit and not to start smoking than messages without pictures.

Nearly a third of adult men and half of all adult women in low-income countries are illiterate. Pictures will help ensure that they too receive important information empowering them to better protect their health.

In addition to delivering new information, pictures elicit a visceral response in viewers, so their impact is both cognitive (intellectual) and affective (emotional). To improve visual effectiveness, the pictures should be colourful and the largest size possible.

Package inserts: additional health information can be provided through inserts similar to those used with prescription drugs, or on the inner “sliding” part of packages that have them.

Besides textual information on tobacco addiction and tips for quitting, inserts should contain pictures that illustrate the hazards of tobacco.

Timing: The time given to companies to implement new warnings should be just enough to use up existing stocks and print new packages. In Canada, the regulations took effect after six months. Tobacco companies will typically ask for a longer time, but 3 to 6 months is sufficient.

The tobacco industry usually tries to delay or block more effective warnings. Countries should be prepared to face these challenges.

Legal challenges are often based on constitutional rights such as free speech, or trade practices. Some constitutions guarantee the right to life, and inducements to smoke or failure to warn of the health consequences, could be argued to infringe this right.

The case for tobacco control measures, including stronger health warnings, is compelling, especially from a human rights and consumer rights perspective. Cigarette companies should have at least the same obligations as drug companies to inform users fully of the risks of using their products.

Moreover, health-warning regulations should specify that displaying health warnings on tobacco products does not relieve tobacco companies of their liability for damages caused by the use of their tobacco products.

Political will to initiate or implement tobacco control reforms may be lacking for a variety of reasons. Some politicians fear that tobacco control would harm the economy and worsen unemployment.

But sound economic evidence shows that tobacco control efforts typically have no net negative impact on employment and can even increase employment. Nevertheless, given the industry influence and power, political challenge remains significant.

Effective cooperation among health agencies, health professionals and the media can counter the influence of tobacco companies. Intensive media campaigns, and grassroots lobbying are needed as well. The issue can be framed as a moral and legal obligation on the part of tobacco companies to properly inform consumers after decades of misleading consumers.