Evidence suggests that health warnings and messages are likely to be more effective if they elicit unfavourable emotional associations with tobacco use and when the information is personalised to make the health warnings and messages more believable and personally relevant. The effectiveness of graphic fear-inducing images is supported by surveys and focus groups with smokers. For example, an extensive public consultation was conducted by the UK Department of Health that received more than 20,000 responses. The highest rated warnings were generally those that included the “hardest hitting” messages and images, including graphic pictures of the health effects of smoking. Similarly in Thailand, a majority of 2,183 respondents from a public opinion poll in 2003 rated the images of smoking cause lung, mouth and throat cancers as the highest and most suitable picture for health warnings. In Malaysia, a graphic health warning efficacy testing found that the use of vivid photos with a high degree of severity and fear appeal have the potential to evoke strong emotion and stimulate thinking.
Health warnings and messages that generate negative emotions such as fear can be effective, particularly when combined with information designed to increase motivation and confidence in tobacco users in their ability to quit. In fact, research in the field of health communication indicates that messages with emotionally arousing content are more likely to be noticed and processed by smokers. The most consistent finding from this literature is that fear appeals are effective when paired with strong efficacy messages for a specific outcome (i.e. quitting smoking). A recent meta-analysis of the literature on public health communicat ions concluded that strong fear appeals and high-efficacy messages produce the greatest behavior change, and found no evidence of any adverse or ‘boomerang’ effects for strong fear appeals.
Current International Best Practice
Countries have taken different approaches to message content. For example, in 2009, Brazil implemented the most shocking, fear-arousing images to be implemented in any country. A number of countries in the ASEAN region have also implemented strong pictorial warnings, beginning with Singapore, as well as Thailand, Brunei, Malaysia and others. Research to date suggests that strong warnings such as these are likely to be most effective, particularly when accompanied by a telephone quitline and other forms of cessation support on the package. While Singapore was among the first countries in the world to print a toll-free telephone “quitline” on packages, Australian warnings currently include the greatest amount of quit support integrated with the health warnings. Canada has also set precedents for including cessation information and quit tips on the “inside” of packages, using an insert (see example at right).
Laws and Regulations
Malaysia Control of Tobacco Product Regulations Amendment 2008
Singapore Control of Advertising and Sale of Tobacco (Labelling) Regulation Amendments 2003
Singapore Labelling Regulation Amendment 2006
Thailand Ministry of Public Health Notification 2009