Pictorial Health Warnings: Myths and Facts

Screen Shot 2558-04-07 at 11.36.20“Smokers are adequately informed about the health risks of smoking.”
Screen Shot 2558-04-07 at 11.37.01Smoking causes more than two dozen health effects and one out of every three long-term smokers will die from tobacco use. Very few, if any, smokers are aware of the full range of health effects and most underestimate the severity of these health risks, even in highly-educated countries. Health warnings have been proven to increase awareness of health effects among youth and adults. Even among groups who report high levels of health knowledge, vivid health warnings increase the frequency with which smokers think about the health risks and promote quitting behaviour. It is also important to recognize that children and youth are a primary target of health warnings. Large picture-based warnings can be understood by young children and, in countries with large graphic warnings, young people report very high levels of awareness of health warnings.
Screen Shot 2558-04-07 at 11.36.20“Neither larger warnings nor the use of pictures will be any more effective than the existing textual warnings.”
Screen Shot 2558-04-07 at 11.37.01Research conclusively demonstrates that picture warnings are more effective than text-only messages. The use of pictorial symbols is a common and effective feature of health warnings for a wide variety of consumer products. Health warnings with pictures are significantly more likely to draw attention and result in greater processing, and memory of the accompanying text. Picture warnings also encourage individuals to imagine health consequences and are more likely to be accessed when an individual is making relevant judgments and decisions. Experimental research, market-research, and large population-based surveys in countries that have implemented picture warnings all demonstrate that graphic warnings are more likely to be noticed and read by smokers, and are associated with stronger beliefs about the health risks of smoking, as well as increased motivation to quit smoking.Picture-based warnings are essential in communicating health information to people with lower literacy rates. This is particularly important considering that, in most countries, smokers report lower levels of education than the rest of the population. Picture warnings can be understood by those who speak different languages, as well as by youth and young children who may not be able to read.
Screen Shot 2558-04-07 at 11.36.20“There is no serious evidence that the warnings have any real impact on tobacco usage.”
Screen Shot 2558-04-07 at 11.37.01Health warnings can promote cessation behavior and larger pictorial warnings are most effective in doing so. Significant proportions of adult and youth smokers report that large comprehensive warnings have reduced their consumption levels, increased their likelihood of quitting, increased their motivation to quit, and increased their likelihood of remaining abstinent following a quit attempt. At least three longitudinal studies-two with adults and one with youth-have demonstrated an association between viewing and thinking about health warnings and subsequent cessation behavior, one of which was conducted with nationally representative samples of smokers in Canada, Australia, the UK and the US. Increases in the use of cessation services have also been associated with health warnings. Research conducted in the UK, the Netherlands, Australia, and Brazil has examined changes in the usage of national telephone “helplines” for smoking cessation after the contact information was included in package health warnings. Each of these studies reports significant increases in call volumes. For example, calls to the toll-free smoking cessation helpline in the Netherlands increased more than 3.5 times after the number was printed on the back of one of 14 package warnings.
Screen Shot 2558-04-07 at 11.36.20“Health warnings do not deter youth from starting.”
Screen Shot 2558-04-07 at 11.37.01Large pictorial warnings are especially effective among youth. Population-based surveys indicate that significant proportions of youth non-smokers, including the most vulnerable youth populations in Canada, the UK, and Australia report that warnings have discouraged them from smoking. Between one-fifth and two-thirds of youth non-smokers indicated that the warnings had ‘helped them from taking up smoking’ in Canada and Australia, and approximately 90% of youth non-smokers in a national UK survey reported that the warnings “put them off smoking.” Longitudinal surveys in Australia have also found that experimental and established smokers were more likely to think about quitting and forgo cigarettes after the implementation of large pictorial warnings, while intention to smoke was lower among youth who had talked about the warning labels. Finally, nationally representative surveys conducted in 2008 with over 26,000 respondents from 27 EU member states and Norway found that 3 out of 10 non-smokers in the EU reported that health warnings are effective in preventing them from smoking. Levels were highest in Romania, where pictorial warnings were implemented shortly before the survey was conducted, with 6 in 10 non-smokers reporting that the warnings have helped to prevent them from smoking.Large picture health warnings can also reduce a brand’s appeal among youth and the impact of package displays at retail outlets to which children are frequently exposed. Overall, all of the evidence conducted to date suggests that comprehensive health warnings help to prevent smoking initiation, and that larger pictorial warnings are most effective in doing so.
Screen Shot 2558-04-07 at 11.36.20“FCTC does not require parties to implement pictorial health warnings.”
Screen Shot 2558-04-07 at 11.37.01The original text in FCTC Article 11 states that Parties “may” use pictorial warnings. However, the Guidelines for Article 11- guidelines that are intended to explain and assist implementation of the Articles – state that “pictures are superior” and that Parties should consider adopting pictures. The revised language in the Guidelines reflect the broader adoption of pictorial warnings around the world as well as the growing evidence base that has clearly demonstrated the superiority of pictorial warnings over text warnings.
Screen Shot 2558-04-07 at 11.36.20“There is no need for mandatory warnings.”
Screen Shot 2558-04-07 at 11.37.01Virtually every jurisdiction in the world has some form of mandatory warning label and Article 11 of the WHO FCTC treaty requires mandatory warnings. Voluntary warnings are typically far weaker than mandatory warnings, and mandatory regulations ensure that all consumers are receiving the same level of health information on packages.
Screen Shot 2558-04-07 at 11.36.20“There is no need to introduce new warnings or pictorial warnings.”
Screen Shot 2558-04-07 at 11.37.01Like any advertising or health communication, health warnings must be regularly updated to maintain their maximum impact over time. Picture warnings appear to sustain their impact longer than text-warnings, but all warnings should be “refreshed” with new messages and pictures every two to four years. When developing new warnings some regulators plan ahead and develop multiple sets of warnings that will be rotated after a set time period.
Screen Shot 2558-04-07 at 11.36.20“Mandatory health warnings constitute an expropriation of the tobacco industry’s packages and trademarks and are an assault on free enterprise and the national economy.” “The Ministry of Commerce is worried about violation of intellectual property rights.”
Screen Shot 2558-04-07 at 11.37.01Tobacco companies have argued that pictorial warnings represent an unjustified expropriation of the pack and violate intellectual property rights. In jurisdictions such as Canada, the European Union, Brazil, and India the tobacco industry has challenged the government’s right to impose pictorial warnings. In all of these cases, the courts have upheld the government’s right to impose pictorial warnings. Indeed, the tobacco industry has yet to mount a successful legal challenge to prevent pictorial warnings. For example, in response to a legal challenge of the Canadian Tobacco Act, the court found that the tobacco companies’ right to advertise their products could not be given the same legitimacy as the federal government’s duty to protect public health. In short, the courts have ruled that graphic warnings are warranted considering the societal costs of smoking. Manufacturers in the European Union have also argued that the labelling directive infringed on Article 20 of the Agreement on the Trade-related Aspects of Intellectual Property Rights (‘the TRIPs Agreement’) as set out in the WTO Agreement. The European Court of Justice dismissed this argument and upheld the labelling law.
Screen Shot 2558-04-07 at 11.36.20“The warnings ‘demonize’ smokers and make them feel like outcasts.”
Screen Shot 2558-04-07 at 11.37.01Tobacco manufacturers commonly portray more comprehensive health warnings as an example of the government attacking or harassing smokers. In fact, there is evidence from a number of countries that large pictorial warnings are not only supported by a strong majority of non-smokers, but also by most smokers. Indeed, many smokers welcome more health information on their packages, particularly when it includes support for quitting. In addition, support for large pictorial warnings typically increases after they have been implemented and increases over time. Therefore, industry claims that comprehensive warnings represent government attacks on smokers are not shared by most smokers themselves.
Screen Shot 2558-04-07 at 11.36.20“Pictorial warnings are too morbid and socially unacceptable.”
Screen Shot 2558-04-07 at 11.37.01Every jurisdiction has the freedom to select the images that will appear on packages and can ensure that warnings are culturally appropriate. Smokers themselves consistently select the graphic depictions of health effects and fear-arousing images as the most effective health warnings. In every survey that has been conducted to date, strong majorities of the public support large graphic warnings, including a majority of smokers themselves. Although these images may be unpleasant to look at, they accurately and truthfully depict the health consequences of smoking.
Screen Shot 2558-04-07 at 11.36.20“If the government wants to put out those messages, it should use billboards or tv commercials.”
Screen Shot 2558-04-07 at 11.37.01Anti-smoking messages using billboards and TV can be a very effective tobacco control measure. However, advertising through these channels can be very costly and requires resources and planning to sustain. In contrast, cigarette health warnings cost governments very little or nothing to implement, and are self-sustaining. Cigarette packages also provide unique reach and frequency of exposure: pack-a-day smokers are potentially exposed to the warnings over 7,000 times per year, including at the time of sale and with each smoking act. Finally, health warnings also fulfill a government’s responsibility to provide adequate warnings for consumer products that kill half of all long term users.
Screen Shot 2558-04-07 at 11.36.20“It is expensive and technically difficult to design new, pictorial based health warning labels, especially for small companies and home industries.”
Screen Shot 2558-04-07 at 11.37.01Tobacco manufacturers have previously argued that they lack the technology to print colour pictorial warnings or that the costs of altering their existing printing methods would be prohibitive. Although manufacturers must bear the costs of redesigning their printing practices, such as the costs of re-etching press cylinders or preparing new lithographic printing plates, the technology required to print colour warnings is widespread. Small companies and “home industries” also have several options, including printing health warnings on stickers or adhesive labels that can be permanently applied to a variety of packages that are manufactured to a lower standard. This approach has been used in India, where many packages are sold in plastic wrapping, rather than carefully manufactured packages.
Screen Shot 2558-04-07 at 11.36.20“It is too expensive and technically difficult for us to keep changing the warning labels on tobacco packaging.”
Screen Shot 2558-04-07 at 11.37.01Regulations requiring new health warnings typically include advance notice to allow manufacturers to make the necessary preparations for the new warnings. For example, many jurisdictions give the industry 6 or 12 months notice following the official announcement of new regulatory standards. In addition, regulators can reduce the burden on manufacturers by providing specific provisions and supplying manufacturers with high quality images of the new warnings.
Screen Shot 2558-04-07 at 11.36.20“Printing pictorial health warnings is not feasible in developing countries.”
Screen Shot 2558-04-07 at 11.37.01Low and middle income countries were among the first to implement pictorial warnings. In addition, the vast majority of brands sold in low and middle income countries are owned by large multinational tobacco companies, who already manufacture packages with pictorial warnings in dozens of jurisdictions throughout the world.
Screen Shot 2558-04-07 at 11.36.20“Only a few countries have implemented pictorial health warning regulation so far, most of which are developed countries. It is unnecessary that our country be the pioneers in this field.”
Screen Shot 2558-04-07 at 11.37.01Approximately half of all countries that require picture warnings are low and middle income countries. Picture health warnings are no longer “novel” or “cutting edge” policies; rather, they have become the basic standard for package warning labels internationally. There is also evidence that picture warnings are even more effective in low and middle income countries, particular in countries with lower levels of literacy. Text-only health warnings have little or no effect among those who cannot read. This includes illiterate individuals, individuals who may be literate but in a language other than that used for text warnings, as well as young children. The most effective way to reach low-literacy smokers is to include pictures, which can be universally understood. This is especially important when considering the effectiveness of health warnings among young children, few of whom may be able to read. Thus, large pictorial health warnings may be even more effective in low and middle income countries.
Screen Shot 2558-04-07 at 11.36.20“Countries should move step by step to implement text warnings first and then change to pictorial health warnings.”
Screen Shot 2558-04-07 at 11.37.01Given that pictorial health warnings are superior to text warnings, there is no rationale for delaying their implementation. Delaying the implementation of pictorial warnings withholds the best quality health information from tobacco consumers and the public.
Screen Shot 2558-04-07 at 11.36.20“Pictorial health warnings will lead to more smuggling.”
Screen Shot 2558-04-07 at 11.37.01There is no evidence that graphic health warnings have lead to an increase in smuggling in any jurisdiction. In fact, large picture warning may help to reduce smuggling: because each country has a unique set of warnings, large picture warnings make contraband cigarettes easier to identify in most cases.
Screen Shot 2558-04-07 at 11.36.20Pictorial health warnings will increase the price of cigarettes, cause massive job losses, and hurt government revenue.”
Screen Shot 2558-04-07 at 11.37.01There is no evidence from the dozens of countries that have implemented graphic health warnings to date that pictorial warnings increase cigarette prices, lead to job losses, or hurt government revenue. Comprehensive picture warnings do have the potential to increase quitting, but no single measure is capable of massive, sudden declines in tobacco prevalence in a manner that would lead to massive job losses. To the extent that tobacco companies experience reduced revenue due to comprehensive health warnings, these reductions will be offset by improvements in population level health, reduced health care expenditures and greater productivity of workers.
Screen Shot 2558-04-07 at 11.36.20“Many countries require tar, nicotine, and carbon monoxide measurements to be printed on packs, our government should do it also.”
Screen Shot 2558-04-07 at 11.37.01The emission numbers printed on packages are the same numbers that tobacco companies have used in misleading advertising that markets “low tar” cigarettes as an alternative to quitting. Printing emission numbers on packages reinforces this deceptive marketing campaign and the false belief that low tar cigarettes are less hazardous: there is no association between the machine-generated emission numbers printed on packages and the health risk of different brands. Therefore, regulations that require emission numbers to be printed on packages are not only ineffective, but harmful regulatory practices. Scientific bodies, including the World Health Organization’s scientific group on tobacco product regulation, have called for the removal of emission numbers from packages. A growing number of countries have removed tar and nicotine numbers from packs, including Australia, Thailand, and others. Countries such as Canada and the European Union have also signaled their intention to do the same.
Screen Shot 2558-04-07 at 11.36.20“Printing tar and nicotine yields will allow smokers to choose brands with higher or lower yields as they desire.”
Screen Shot 2558-04-07 at 11.37.01The majority of smokers who use tar and nicotine numbers to choose brands do so in the false belief that these brands may be less harmful than “regular” or “higher tar” brands. There are many other brand elements that smokers can use to select brands. Indeed, in countries such as the United States, where tar and nicotine numbers are not required on packs, very few companies choose to print these numbers voluntarily.
Screen Shot 2558-04-07 at 11.36.20“Requiring the printing of ingredients is a violation of trade secrecy rights.”
Screen Shot 2558-04-07 at 11.37.01To date, no countries require a full list of ingredients to be printed on packs, in part because tobacco contains thousands of chemicals and a long list of ingredients. FCTC Articles 9 and 10 are developing new guidelines for mandatory reporting of tobacco ingredients to regulators, as well as recommendations for communicating this information directly to consumers.