THE TRUTH:

Health warnings on cigarette packs:

The bigger the better

* At least two people die in a day due to mouth cancer in Lanka

* One in 10 global deaths is caused due to tobacco use

* Tobacco use is responsible for causing more than 10 types of cancers, 18 other diseases

* In one year more than five million people died from tobacco use

* It is the second major cause of mortality in the world

Manjari Peiris The salience of health warnings depends upon the size and position of the warning message. Youths and adults are more likely to recall larger warnings, rate larger warnings as having greater impact, and often equate the size of the warning with the magnitude of the risk.

A recent experimental research study conducted in Canada found that increasing the size of pictorial warnings from the current size of 50 percent of the principal display area to 75 percent, 90 percent and 100 percent enhanced their impact among adult smokers, youth smokers, as well as ‘vulnerable’ youth non-smokers.

A recent study conducted in Australia, where pictorial warnings cover 90 percent of the front and 30 percent of the back of packs, also found that the effectiveness of warnings could be improved by increasing the size of the warnings further.

Professor David Hammond of the Department of Health Studies and Gerontology, University of Waterloo, Canada, reveals that evidence indicates that the impact of health warnings depends upon their size and design of pictorial health warnings depicted on cigarette packets.

Professor Hammond who is the sole author of this study and examined the impact of the size of pictorial health warnings on tobacco products, says that obscure text only warnings appear to have little impact and prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non smokers who develop increased health knowledge and perceptions of risk can ultimately promote smoking cessation.

The evidence also indicates that comprehensive warnings are effective among youths and may help prevent smoking initiation. Professor Hammond said pictorial health warnings that elicit strong emotional reactions are significantly more effective.

The study findings reveal that health warnings on packages are among the most direct and prominent means of communicating with smokers. Larger warnings with pictures are significantly more effective than smaller text only messages. One in 10 global deaths is caused due to tobacco use. It is the second major cause of mortality in the world. In one year more than five million people died from tobacco use. It is more than the number died of tuberculosis, HIV/AIDS and malaria combined. Tobacco use is responsible for causing more than 10 types of cancers and 18 other diseases.

Health warnings on tobacco packages have emerged as an important medium for communicating the health risks of tobacco use to consumers.

Tobacco packages provide high reach and frequency of exposure ‘pack-a-day smokers are potentially exposed to the warnings over 7,000 times per year’as well as an opportunity to communicate with smokers during the act of smoking. Tobacco packs also serve as portable advertisements with high levels of exposure among non-smokers: unlike many other consumer products, cigarette packs are displayed each time the product is used and are often left in public view between users.

Tobacco packages are also prominent in retail outlets, where product displays are common and typically increase in prominence as other forms of tobacco marketing are restricted.

International guidelines for cigarette health warnings have been established under Article 11 of the WHO’s Framework Convention on Tobacco Control (FCTC), the first international treaty devoted to public health.

Study findings reveal that in countries with large pictorial warnings, such as Thailand, Australia and Uruguay, more than 85 percent of smokers have cited packages as a source of health information.

A notable exception is the low levels of salience for more obscure warnings that appear on the side of packages. The findings suggest that small text warnings are associated with low levels of awareness and poor recall.

Health warnings have also been found to be a prominent source of health information for non-smokers and the public. For example, 86 percent of non-smokers in Canada agreed in a national survey that the warnings on cigarette packs provide them with important health information.

Non-smokers also report high levels of recall for specific health messages on packs. For example, more than a third of adult non-smokers in Australia could recall at least one specific pictorial warning on cigarette packs in a 2008 survey. In the UK, a national survey of youths in 2008 found that approximately 60 percent of non-smokers could recall a specific warning displayed on the front of UK packs.

Features that distinguish the warning messages from the package design have also been found to increase the impact of health warnings. Using a box or perimeter around the outside of the message has been found to increase the salience and recall of warnings, while contrasting colours, such as black lettering on a white background, are the easiest to read and increase comprehension.

Cross-sectional surveys in Canada during the 1990s found that the majority of smokers reported that package warning labels were an important source of health information and had increased their awareness of the risks of smoking.

An Australian study found that, relative to non-smokers, smokers demonstrated an increase in their knowledge of the main constituents of tobacco smoke and identified significantly more disease groups following the introduction of new Australian warning labels in 1995. A wide variety of research has demonstrated the effectiveness of using pictures and imagery in health communications.

These studies suggest that health warnings with pictures are significantly more likely to draw attention, result in greater information processing and improve memory for the health message.

A study conducted in China in 2008 found that smokers were significantly more likely to rate pictorial warnings as more effective than text warnings for motivating smoking cessation and for preventing smoking among youths. A research in Canada approximately five years after the introduction of pictorial warnings concluded that: “The picture was generally the first thing people looked at and related to. It determined the strength of the warning’s emotional impact and noticeability. For many participants, the picture played the key role in understanding the message, and tended to override the meaning conveyed by the words in the headline.”

Since 2001, when Canada became the first country to implement pictorial health warnings on cigarette packs, a series of population-based surveys have compared the effectiveness of text versus pictorial warnings. These findings are consistent with both experimental studies and government-commissioned research: pictorial warnings are more likely to be noticed and read by smokers, are associated with stronger beliefs about the health risks of smoking, as well as increased motivation to quit smoking.

Picture warnings also appear to be effective among youths. Approximately six years after their introduction, more than 90 percent of Canadian youths agreed that picture warnings on Canadian packages had provided them with important information about the health effects of smoking cigarettes, are accurate, and made smoking seem less attractive.

Other national surveys of Canadian youths suggest similar levels of support and self-reported impact.

A recent longitudinal evaluation of pictorial warnings among Australian schoolchildren found that students were more likely to read, attend to, think about, and talk about health warnings after the pictorial warnings were implemented in 2006.

In addition, experimental and established smokers were more likely to think about quitting and to forgo smoking a cigarette, while intention to smoke was lower among those students who had talked about the warning labels and had forgone cigarettes.

Surveys among former smokers also suggest that health warnings promote long-term abstinence from smoking. Studies conducted to date suggests that comprehensive health warnings can promote cessation behavior and discourage initiation, and that larger pictorial health warnings are most effective in doing so.

Warnings that depict elements of human suffering, depictions of personal experience including the social and emotional impact of tobacco use, or consequences for quality of life have also been found to be effective.

Health warnings that are new or periodically updated are likely to have greater impact than ‘older’ warnings. Research also indicates that both adult and youth smokers report graphic warnings to be a credible source of information. For example, six years after the implementation of pictorial warnings in Canada, 86 percent of adult smokers and 92 percent of youth smokers agreed that the warnings were accurate.

Similarly, more than 90% of Australian smokers reported that large pictorial health warnings were ‘believable’, a slight increase from the levels reported in 2000 when text warnings appeared on Australian packages. Surveys in EU member states in 2008 found that more than half of EU citizens supported the effectiveness of adding a picture to text-only health warnings, while more than 87 percent of respondents in a nationally representative survey in Russia agreed that graphic warnings should be mandated on packages, including 80 percent of smokers.

Similar levels of support have been recorded among youth. For example, in Canada more than 90 percent of youths agreed that picture warnings on Canadian packages have provided them with important information about the health effects of smoking cigarettes.

Health warnings on cigarette packages have a broad population reach and represent a direct means of communicating the risks of smoking.

Considerable proportions of smokers report that warning labels increase their motivation to quit and help them to sustain abstinence after quitting, and the use of effective cessation services increases after new health warnings have been implemented.

The World Health Organisation identified and recommended comprehensive health warnings on packages among the six key measures required to address the global tobacco epidemic. In Sri Lanka, at least two people die in a day due to mouth cancer. Tobacco smoking is responsible for 70 percent of lung cancers. Similarly the number of those who die of heart attacks is over 150 a day.

The majority are either direct or indirect smokers. Daily around 40-50 people die of strokes and of them the majority are those who have got addicted to tobacco smoking.

The government is spending 22 percent of the total health budget to treat those who fall sick of tobacco smoking.

The Health Minister has stated that the expectation of the government is not to increase the profits of multinational companies, but to enhance the health of people.

Whoever works against this principle, the government would take the measures favourable to people. We should take every measure to combat the challenge against the people’s health by supporting the bold step taken by the Health Minister.