Smokers benefit from information about tobacco risks and quitting
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 (World Health Organization 2002). Studies show that many smokers still do not know that tobacco causes disease and premature death. Many others know little beyond a vague notion that “smoking is bad for you”— even in the US, where a great deal of information is easily available from multiple sources (USDHHS 1989). 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 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 (WHO 1997). 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 (Environics 2002, Costa e Silva 2002). 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 espcially strong among people with low incomes and education (Costa e Silva 2002). 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 (Borland 1997). Other studies report similar findings. 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 (Mahood 1995).
Package warning efficiently target smokers
|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 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”(Mahood 1995).
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 "Lights", "Ultralight", "Slim", and "Superslim" on cigarette packages. Picture-based warnings are being considered in Australia and Thailand, and an 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 require 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 (Aftab et al 1999). This is unacceptable, especially since about 80% of the world’s smokers live in developing countries (World Bank 1999).
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 (Études de marché Créatec 1999).
- 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 (Liefield et al 1999). 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 colorful 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.
ResourcesExamples of Canadian and Brazilian health messages and pictures: http://www.hc-sc.gc.ca/english/media/photos/tobacco_labelling/index.htm
Agencia nacional de vigilancia sanitaria (for Brazilian health warnings—in Portuguese) http://www.anvisa.gov.br/divulga/noticias/040601_1.htm
Evaluations and advice
Canadian Cancer Society. Controlling the Tobacco Epidemic: Selected Evidence in Support of Banning All Tobacco Advertising and Promotion, and Requiring
Large, Picture-Based Health Warnings on Tobacco Packages. Ottawa: Canadian Cancer Society, International Union Against Cancer, April 2001 http://www.globalink.org/tobacco/docs/packaging/evidence.doc
Corrao MA, Guindon GE, Sharma N, Shokoohi DF (eds). Tobacco Control Country Profiles, American Cancer Society, Atlanta, GA, 2000 http://www5.who.int/tobacco/page.cfm?sid=57
International Union Against Cancer, International Union Against Tuberculosis and Lung Disease, World Heart Federation, International Non Governmental Coalition
Against Tobacco. Memorandum re ‘Package Warnings’ http://www.ontario.cancer.ca/Siteboth/files/TOBUICCwarninglabels.pdf
PAHO. Developing Legislation for Tobacco Control. May, 2002 provides basic information and legal templates for tobacco control measures including warnings
Aftab, M, D Kolben, P Lurie. International cigarette labelling practices. Tobacco Control 1999; 8:368–372.
Borland R. Tobacco health warnings and smokingrelated cognitions and behaviours, Addiction 1997 Nov.; 92(11):1427-35.
Costa e Silva, VL. Presentation to EU Commission on enforcement of health warnings in Brazil. Brussels 2002.
Environics Research Group Limited. Evaluation of New Warnings On Cigarette Packages, January 2002. http://www.cancer.ca/ccs/internet/standard/0,3182,3172_334419_436437_langId-en,00.html
Environics Research Group Limited. Health Warning Testing, Final Report. June 1999. http://www.hc-sc.gc.ca/hecs-sesc/tobacco/pdf/health_warning_testing_final.pdf
Mahood G. Canadian tobacco package warning system, Tobacco Control 1995; 4:10-14.
US Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress. A report of the surgeon general, 1989.
Willemsen MC. The altered view of tobacco products: The effects of the new health warmings on smokers. DEFACTO, The Hague, Netherlands 2002.
World Bank. Curbing the Epidemic: governments and the economics of tobacco control, World Bank 1999, see also: Jha P. and F. Chaloupka (editors). Tobacco Control in Developing Countries, published by OUP for the World Bank and World Health Organization, 2000. both on line at http://www.worldbank.org/tobacco Zatonski, W, K Przewozniak, M Porebski. “The positive health impact of enlarged cigarette pack warning labels in Poland,” Paper presented at the 2nd European Conference on Tobacco or Health, Las Palmas de Gran Canaria, Spain, 23-27 February 1999.