Do cigarette health warning labels comply with requirements: A 14-country study

The Framework Convention on Tobacco Control, a global health treaty ratified by over 175 countries, calls on countries to ensure that tobacco packages carry health warning labels (HWLs) describing the harmful effects of tobacco use. We assessed the extent of compliance with 14 countries' HWL requirements. Unique cigarette packs were purchased in 2013 using a systematic protocol in 12 distinct neighborhoods within three of the ten most populous cities in the 14 low- and middle-income countries with the greatest number (count) of smokers. HWL compliance codebooks were developed for each country based on the details of country-specific HWL requirements, with up to four common compliance indicators assessed for each country (location, size, label elements, text size). Packs (n = 1859) were double coded for compliance. Compliance was examined by country and pack characteristics, including parent company and brand family. Overall, 72% of coded cigarette packs were compliant with all relevant compliance indicators, ranging from 17% in the Philippines to 94% in Mexico. Compliance was highest for location of the warning (ranging from 75%–100%) and lowest for warning size (ranging from 46%–99%). Compliance was higher for packs bought in high SES neighborhoods, and varied by parent company and brand family. This multi-country study found at least one pack in every country – and many packs in some countries – that were not compliant with key requirements for health warning labels in the country of purchase. Non-compliance may be exacerbating health disparities. Tobacco companies should be held accountable for complying with country HWL requirements.     

2019年中国中学生烟草调查结果发布

评价不同烟盒包装对青少年的警示作用,为改进我国烟盒包装提供客观依据。

采用多阶段整群抽样方法,在上海市黄浦区2所初中和2所高中的学生中进行自填式问卷调查,共回收有效问卷1 238份。使用EpiData 3.1录入数据,SPSS 20.0进行数据分析。

69%的调查对象支持我国烟盒包装印刷疾病图片,81.58%的调查对象支持图形警示应该占烟盒包装的面积>70%。图形健康警示标签的警示效果优于纯文字警示标签（P<0.05）,其中真实图片的警示效果优于抽象图片。此外,真实图文警示标签在预防青少年吸烟、受支持程度这2个方面排序得分最高,与抽象图文警示标签和纯文字警示标签差异有统计学意义（P<0.05）。

图形健康警示的烟盒比纯文字健康警示对青少年的警示作用更强。青少年对采用图片警示持支持态度。建议在烟盒包装上印刷真实疾病图片的图形健康警示,以发挥烟盒包装健康警示的最大效果。

     

Representation,Exemplification, and Risk: Resonance of Tobacco Graphic Health Warnings Across Diverse Populations

As countries implement Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control, graphic warning labels that use images of people and their body parts to illustrate the consequences of smoking are being added to cigarette packs. According to exemplification theory, these case examples—exemplars—can shape perceptions about risk and may resonate differently among demographic subpopulations. Drawing on data from eight focus groups (N = 63) with smokers and nonsmokers from vulnerable populations, this qualitative study explores whether people considered exemplars in their reactions to and evaluations of U.S. graphic health warning labels initially proposed by the Food and Drug Administration. Participants made reference to prior and concurrent mass media messages and exemplars during the focus groups and used demographic cues in making sense of the images on the warning labels. Participants were particularly sensitive to age of the exemplars and how it might affect label effectiveness and beliefs about smoking. Race and socioeconomic status also were salient for some participants. We recommend that exemplars and exemplification be considered when selecting and evaluating graphic health warnings for tobacco labels and associated media campaigns.     

烟草包装对上海市居民健康警示效应调查

目的了解公众对警示包装的知晓程度以及图片警示在公众中的警示效应,评价这一控烟措施的有效性和可行性。方法采用多阶段整群抽样方法选取上海市某区居民2300人,包括吸烟者和非吸烟者,进行人户调查,采用自填式问卷调查。结果76．7％的居民知道我国现有的烟盒上印有健康警示。79．6％的公众认为图片警示可以减少吸烟者的吸烟量;78．7％的公众认为图片警示可以防止青少年吸烟;72．9％的公众认为图片警示可以减少人们之间互相递烟的行为。相对于不知道和没注意过烟包警示的人群,知道烟包警示的人更支持更换图片警示,OR值为1．43（95％CI：1．09～1．88）;和非吸烟者相比,吸烟者和戒烟者支持更换图片警示比例较低,OR分别为0．22（95％CI：0．17～0．28）和0．38（95％CI：0．23～0．60）。结论疾病图片警示可以在公众中产生广泛的警示效应,公众对更换图片警示包装呈支持态度。     

Cost effectiveness of tobacco control policies in Vietnam

Background

Tobacco smoking is one of the leading public health problems in the world. It is also possible to prevent and/or reduce the harm from tobacco use through the use of cost-effective tobacco control measures. However, most of this evidence comes from developed countries and little research has been conducted on this issue in developing countries.

Objective

The objective of this study was to analyse the cost effectiveness of four population-level tobacco control interventions in Vietnam.

Methods

Four tobacco control interventions were evaluated: excise tax increase; graphic warning labels on cigarette packs; mass media campaigns; and smoking bans (in public or in work places). A multi-state life table model was constructed in Microsoft® Excel to examine the cost effectiveness of the tobacco control intervention options. A government perspective was adopted, with costing conducted using a bottom-up approach. Health improvement was considered in terms of disability-adjusted life-years (DALYs) averted. All assumptions were subject to sensitivity and uncertainty analysis.

Results

All the interventions fell within the definition of being very cost effective according to the threshold level suggested by the WHO (i.e. Conclusions All four interventions to reduce the harm from tobacco use appear to be highly cost effective and should be considered as priorities in the context of Vietnam. The government may initially consider graphic warning labels and tax increase, followed by other interventions.     

2008年中国烟盒包装健康警示效果评估

目的评估中国居民对中国烟盒健康警示以及国外图形及文字方式健康警示有效性的感知。方法在北京、上海、昆明、银川4个城市共调查1169人,包括成年吸烟者、非吸烟者以及青少年,男女各半。以中华牌烟盒为背景,制作了10种不同的健康警示,包括我国大陆地区文字警示新版和旧版共2种,译成中文的国外图文警示共4种,以及以这4种图文警示为基础删除图形后的国外文字警示4种。调查对象对10种健康警示进行评分和排序。结果在促使吸烟者戒烟及阻止青少年吸烟方面,图文警示有效性评分最高,国外文字警示次之,中国文字警示旧版有效性评分最低。排序结果与评分结果基本一致,均表现为图文警示优于国外文字警示,优于中国文字警示。在不同研究对象组、城市、性别的分析中,结果一致。结论中国新烟盒健康警示与旧的警示相比,效果提高非常有限。中国应切实履行《烟草控制框架公约》第11条实施准则的要求,使用图形加文字方式的健康警示,向公众有效传播吸烟的健康危害知识。     

Graphic warning labels on plain cigarette packs: Will they make a difference to adolescents?

Graphic warning labels and plain cigarette packaging are two initiatives developed to increase quit behaviour among smokers. Although a little is known about how adolescents interpret graphic warning labels, very few studies have examined how plain cigarette packaging would affect adolescents' perceptions of cigarette smoking and smoking behaviour. We explored how teens interpret and respond to graphic warning labels and the plain packaging of cigarettes, to assess the potential these strategies may offer in deterring smoking initiation. Twelve focus group interviews with a sample of 80 14-16 year old students from a diverse range of schools in Auckland, New Zealand were undertaken between June and August 2009. Textual analysis revealed that graphic warning labels may influence adolescents by reiterating a negative image of smokers. Graphic warning on a plain cigarette pack increased the attention paid to graphic warning labels and the overall perceptions of harm caused by cigarette smoking, and reduced the social appeal of cigarette smoking. This research offers evidence on how adolescents are appraising and interpreting graphic warning labels, and explores how dominant appraisals may affect the role graphic warning labels play in preventing smoking. Not only would plain cigarette packaging enhance the salience and impact of graphic warning labels, but it would potentially bolster the overall message that cigarette smoking is harmful. In the context of a comprehensive tobacco control programme, graphic warning labels on plain cigarette packaging present an explicit message about the risks (to health and image) associated with cigarette smoking.     

Nature and Potential Impact of Alcohol Health Warning Labels: A Scoping Review

Alcohol is toxic to human health. In addition to providing nutritional information, labels on alcohol products can be used to communicate warnings on alcohol-related harms to consumers. This scoping review examined novel or enhanced health warning labels to assess the current state of the research and the key studied characteristics of labels, along with their impact on the studied outcomes. Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched between January 2010 and April 2021, and 27 papers were included in the review. The results found that most studies were undertaken in English-speaking populations, with the majority conducted online or in the laboratory setting as opposed to the real world. Seventy percent of the papers included at least one cancer-related message, in most instances referring either to cancer in general or to bowel cancer. Evidence from the only real-world long-term labelling intervention demonstrated that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Alcohol health warning labels should be seen as tools to raise awareness on alcohol-related risks, being part of wider alcohol policy approaches.     

Adolescents' Perceptions of Cigarette Brand Image: Does Plain Packaging Make a Difference?

PurposeTo examine the effect of plain packaging on adolescents' perceptions of cigarette packs, attributes of smokers, and expectations of cigarette taste, and to identify the effect of increasing the size of pictorial health warnings on appraisal of plain packs.MethodsWe used a 5 (degree of plain packaging and graphic health warning)× 3 (brand type) between-subjects experimental design, using a Web-based methodology to expose adolescents to one randomly selected cigarette pack, during which respondents completed ratings.ResultsWhen brand elements such as color, branded fonts, and imagery were progressively removed from cigarette packs, adolescents perceived packs to be less appealing, rated attributes of a typical smoker of the pack less positively, and had more negative expectations of cigarette taste. Pack appeal was reduced even further when the size of the pictorial health warning on the most plain pack was increased from 30% to 80% of the pack face, with this effect apparent among susceptible nonsmokers, experimenters, and established smokers.ConclusionsRemoving as much brand information from cigarette packs as possible is likely to reduce positive cigarette brand image associations among adolescents. By additionally increasing the size of pictorial health warnings, positive pack perceptions of those who are at greater risk of becoming regular addicted adult smokers are most likely to be reduced.     

A consumer evaluation of health warning labels on cigarette packages in Canada

This paper reports on results of a study that examined consumers' evaluation of health warning labels on cigarette packages in Canada. Some health warning labels were rated, overall, as more effective as well as more believable, convincing and reasonable than others. Analysis of the differences in responses by smokers and non-smokers is also presented.     

A major state tobacco tax increase, the master settlement agreement, and cigarette consumption: the California experience

OBJECTIVES: We evaluated the combined effects on California cigarette consumption of an additional 50 cent per pack state tax imposed by Proposition 10 of January 1999 and a 45 cent per pack increase in cigarette prices stemming from the Master Settlement Agreement (MSA) of November 1998. METHODS: We used quarterly cigarette sales data for the period 1984-2002 to estimate a time-series intervention model adjusting for seasonal variations and time trend. RESULTS: Over the period 1999 through 2002, the combined effect was to reduce cigarette consumption by 2.4 packs per capita per quarter (1.3 billion packs total over the 4-year period) and to raise state tax revenues by $2.1 billion. These effects were similar to the effects of a 25 cent per pack tax increase enacted by Proposition 99 a decade earlier, although with decreased relative effectiveness as measured by percentage of reduction in cigarette consumption divided by percentage of increase in taxation (-0.44 vs -0.60). CONCLUSIONS: A major increase in price through taxation and the MSA provided a strong economic disincentive for smokers in a state with a low smoking prevalence. This effect could be reinforced if part of the MSA payments were devoted to tobacco control programs.     

Reactions of young adult smokers to warning labels on cigarette packages

BACKGROUND: In 1984, the United States Congress enacted legislation requiring four new warning labels for cigarettes; warning labels in the United States have not changed since then. Other countries, such as Canada, have taken a more active and aggressive approach. The purpose of this study was to examine how U.S. smokers and former smokers might respond to stronger and more graphic warnings for U.S. cigarettes packages. METHODS: Data were collected in 2003 and analyzed in 2004. The perceived impact and effectiveness of the more-explicit Canadian labels was examined among young adult smokers (n=572) and former smokers (n=191) between the ages of 18 and 24 years in the United States, using a web-based survey that allowed participants to view both the text-only and the text-plus-graphic warning labels. RESULTS: Both current and former smokers thought that cigarette warning labels with text plus graphics were substantially more of a deterrent than text-only labels. The perceived effectiveness of these labels was not only higher overall, but also for the specific areas of smoking-related health effects, prevention, cessation, and maintenance of abstinence. Few differences were noted by gender. CONCLUSIONS: The findings from this study support previous research that has found that text-plus-graphic warning labels are more salient and potentially more effective than text-only labels.     

Effects of Varying Color,Imagery, and Text of Cigarette Package Warning Labels among Socioeconomically Disadvantaged Middle School Youth and Adult Smokers

ABSTRACT

The U.S. Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 paved the way for the Food and Drug Administration (FDA) to propose nine different graphic warning labels (GWLs) intended for prominent placement on the front and back of cigarette packs and on cigarette advertisements. Those GWLs were adjudicated as unconstitutional on the ground that they unnecessarily infringed tobacco companies’ free speech without sufficiently advancing the government’s public health interests. This study examines whether less extensive alternatives to the original full-color GWLs, including black-and-white GWLs and text-only options, have similar or divergent effects on visual attention, negative affect, and health risk beliefs. We used a mobile media research lab to conduct a randomized experiment with two populations residing in socioeconomically disadvantaged communities: biochemically confirmed adult smokers (N = 313) and middle school youth (N = 340). Results indicate that full-color GWLs capture attention for longer than black-and-white GWLs among both youth and adult smokers. Among adults, packages with GWLs (in either color or black-and-white) engendered more negative affect than those with text-only labels, while text-only produced greater negative affect than the packages with brand imagery only. Among youth, GWLs and text-only labels produced comparable levels of negative affect, albeit more so than brand imagery. We thus offer mixed findings related to the claim that a less extensive alternative could satisfy the government’s compelling public health interest to reduce cigarette smoking rates.     

Pack size, reported cigarette smoking rates, and public health.

The relation between packs containing 25 or 20 cigarettes each and self-reports of daily cigarette intake was examined in surveys of smoking habits from the United States and Canada. More Canadian than US smokers report smoking 25 cigarettes per day (19.3 per cent vs 2.1 per cent). As market share of packs of 25 increases across six regions in North America, reports of smoking 25 cigarettes per day increase. Even if smoke exposure remains constant, smoking statistics are likely to be influenced by pack size.     

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

ABSTRACT

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., “Smoking can kill you”), we examined the impact of adding: (a) text detailing the person’s name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.     

Evaluating the Emotional Impact of Warning Images on Young Adult Smokers and Susceptible Non-Smokers

On-pack tobacco warnings typically feature long-term health risks, which many young adults rationalize or reject. We examined the emotions generated by more proximal warnings to see if we could identify common features among the most effective warnings. Respondents in a sample of 474 smokers and 476 susceptible non-smokers used a modified Geneva Emotion Wheel (GEW) to assess cigarette packs displaying 12 test warnings and one current warning. The strongest emotions aroused in smokers were disgust, disappointment, and regret. Three warnings showing the effect of smoking on babies and animals had significantly higher emotional potency scores than a current health warning. Among susceptible non-smokers, warnings showing harm to animals, child labor, and a dying smoker had the highest emotional potency. Stronger negative emotions were elicited from both smokers and susceptible non-smokers by warnings that featured more proximal outcomes than are typically shown in on-pack tobacco warnings. On-pack warnings that resonate with young people, the group most at risk of smoking and most likely to benefit from quitting, could promote cessation and deter initiation more effectively than warnings depicting long-term health outcomes. The GEW could be used to screen potential warning images to identify those most likely to be worth evaluating.     

Do the Ends Justify the Means? A Test of Alternatives to the FDA Proposed Cigarette Warning Labels

Three studies provide empirical, social scientific tests of alternatives to the originally proposed U.S. Food and Drug Administration (FDA) cigarette package warning labels on health risk beliefs, perceived fear, and effectiveness. Our research addresses questions at the root of the legal disputes surrounding FDA regulation of cigarette package warning labels. Specifically, we describe results from three studies that investigate the mediating role of health beliefs and perceived fear in shaping message effectiveness and intentions to quit. The first study featured nonsmoking young adults, while the second and third studies sampled adult daily smokers. Each study was a randomized experiment with five warning-label image conditions: full-color graphic warning labels, black-and-white graphic warning labels, warning text (no graphic image), Surgeon General’s warning labels, and no warning. Results consistently indicate that graphic warning labels (in both color and black-and-white) promote increased perceptions of fear, which in turn are associated with greater (perceived and actual) effectiveness. We conclude with a discussion of the results, highlighting implications, public policy considerations, and suggestions for future research.     

Effects of publicity and a warning letter on illegal cigarette sales to minors

Abstract: The study aimed to assess rates of illegal cigarette sales to children and the impact on these rates of publicity and a warning letter threatening prosecution. Children aged 12 and 13 made two repeat purchasing attempts, three months apart, at 255 randomly selected tobacco retail outlets in Sydney. A randomly selected 50 per cent of retail outlets which sold cigarettes illegally at the first attempt were sent warning letters threatening prosecution. Publicity about the undercover buying operation was organised between the attempts. At the first attempts, 39 per cent of shops sold cigarettes to the children and 32 per cent sold them at the second attempt. Shops which sold on the first occasion and received warning letters reduced selling by 69 per cent compared to the 40 per cent reduction in shops which sold cigarettes on the first attempt and were not sent warning letters, a net reduction of 29 per cent seemingly attributable to the warning letters (95 per cent confidence interval 8 per cent to 50 per cent). It is extremely easy for children as young as 12 to buy cigarettes. The combined effects of publicity about undercover buying operations and warning letters threatening prosecution seem capable of reducing selling by about 29 per cent. Because of inconsistencies in selling or refusals, future attempts to measure selling rates to children should use repeat purchasing attempts and classify outlets as ‘selling’, ‘not selling’ or ‘sometimes selling’.     

Cigarette package health warnings and interest in quitting smoking --- 14 countries, 2008--2010

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires health warnings on tobacco product packages sold in countries that ratified the WHO FCTC treaty (1). These warnings are expected to 1) describe the harmful effects of tobacco use; 2) be approved by the appropriate national authority; 3) appear on at least 30%, and ideally 50% or more, of the package's principal display areas; 4) be large, clear, visible, and legible in the country's principal language(s); 5) have multiple, rotating messages; and 6) preferably use pictures or pictograms. To assess the effects of cigarette package health warnings on interest in quitting smoking among smokers of manufactured cigarettes aged ≥15 years, this report examines 2008--2010 data from the Global Adult Tobacco Survey (GATS) in 14 WHO FCTC countries. Among men, the prevalence of manufactured cigarette smoking ranged from 9.6% in India to 59.3% in Russia. Among men in 12 of the countries and women in seven countries, >90% of smokers reported noticing a package warning in the previous 30 days. The percentage of smokers thinking about quitting because of the warnings was >50% in six countries and >25% in men and women in all countries except Poland. WHO has identified providing tobacco health information, including graphic health warnings on tobacco packages, as a powerful "best buy" in combating noncommunicable disease (2). Implementing effective warning labels as a component of a comprehensive approach can help decrease tobacco use and its many health consequences.