requirements provide the most direct warning labels are also effective in reducing to sustain their effects longer than weaker health messages to smokers(6,26,27) the appeal and increasing the perception of or more general warnings(28).Because and potentially reach smokers every risk of smokeless tobacco products among smokers recall more readily the warnings time they purchase or consume tobacco youth (31). they have seen recently(40).it is important products(28,29).Warnings are also seen to rotate warning labels periodically and to by non-smokers,affecting their perceptions introduce new ones regularly. of smoking and decisions about initiation, Pictorial warning labels are and ultimately helping to change the especially powerful Warning labels that include pictures image of tobacco and "denormalize"its are most likely to be noticed and rated use (30)(the previous chapter qives details Pictorial labels are more effective than effective by smokers(27,32),and of specific quidelines contained in the text-only warnings(6,28,32-38),in part increasing the size of warning labels also WHO FCTC for characteristics of effective because they are noticed by more people, increases their effectiveness (28).The three warning labels). provide more information,and evoke countries that currently have the largest emotional responses to the images(28,39). pictorial health warning requirements Although most of the evidence currently Pictorial warnings are even more important for cigarette packages(as an average of available has examined the impact of in countries with low literacy rates where the package front and back)are Uruquay health warning labels on the packaging of many people cannot understand written (80%),Mauritius (65%)and Mexico manufactured cigarettes,pictorial health messages.Stronger health warnings tend (65%). INTRODUCTION OF GRAPHIC WARNING LABELS IN CANADA INCREASES SMOKERS'INTENTION TO QUIT 100% 87 90% 80% 70% 60% 50% 40% 30% 20 20% 10% Smokers'intention to quit before Smokers'intention to quit after introduction of pack warnings implementation of pack warnings Source:(29). WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC,2011 23
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2011 23 Smokers’ intention to quit before introduction of pack warnings Smokers’ intention to quit after implementation of pack warnings 20 87 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Proportion of smokers that intended to quit Introduction of graphic warning labels IN CANADA increases smokers’ intention to quit Source: (29). requirements provide the most direct health messages to smokers (6, 26, 27) and potentially reach smokers every time they purchase or consume tobacco products (28, 29). Warnings are also seen by non-smokers, affecting their perceptions of smoking and decisions about initiation, and ultimately helping to change the image of tobacco and “denormalize” its use (30) (the previous chapter gives details of specific guidelines contained in the WHO FCTC for characteristics of effective warning labels). Although most of the evidence currently available has examined the impact of health warning labels on the packaging of manufactured cigarettes, pictorial health warning labels are also effective in reducing the appeal and increasing the perception of risk of smokeless tobacco products among youth (31). Pictorial warning labels are especially powerful Pictorial labels are more effective than text-only warnings (6, 28, 32–38), in part because they are noticed by more people, provide more information, and evoke emotional responses to the images (28, 39). Pictorial warnings are even more important in countries with low literacy rates where many people cannot understand written messages. Stronger health warnings tend to sustain their effects longer than weaker or more general warnings (28). Because smokers recall more readily the warnings they have seen recently (40), it is important to rotate warning labels periodically and to introduce new ones regularly. Warning labels that include pictures are most likely to be noticed and rated effective by smokers (27, 32), and increasing the size of warning labels also increases their effectiveness (28). The three countries that currently have the largest pictorial health warning requirements for cigarette packages (as an average of the package front and back) are Uruguay (80%), Mauritius (65%) and Mexico (65%)
The size of the warning on the front of their smoking(29).About three in 10 warnings also persuade smokers to protect the package is most critical for immediate former smokers reported that the labels had the health of non-smokers by smoking less impact,as packs are generally displayed motivated them to quit and more than a inside their homes and avoiding smoking with the front showing and smokers are quarter said that labels helped them remain near children (43,45). most likely to take cigarettes from packs abstinent(41).In another Canadian study, while looking at the package front(28).The about a fifth of smokers reported reducing placement of warning labels at the top of their consumption as a result of seeing the Health warning labels can be the pack,rather than at the bottom,is also pack warning labels(42) used to promote quit lines likely to increase their visibility and make it more difficult to conceal the warnings in Australia introduced graphic health waming Smokers are more likely to reduce tobacco retail displays. labels in 2006 that caused more than half consumption and think about quitting as of smokers to believe that they had an a result of seeing strong graphic warning After Canada became the first country to increased risk of dying from smoking-related labels(25).Providing direct information introduce large,graphic health warning illness,with 38%feeling motivated to quit about cessation services on tobacco labels on cigarette packages in 2001, (40).Other countries with pictorial warning packaging,in addition to health warnings, smokers who had read,thought about and labels,including Brazil (26),Singapore (43) may further motivate smokers to make discussed the labels were more likely to and Thailand (44),report similar effects a quit attempt.Promoting quit lines by have quit,made a quit attempt,or reduced on smoking-related behaviour.Graphic including telephone numbers directly on 24 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC,2011
24 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2011 The size of the warning on the front of the package is most critical for immediate impact, as packs are generally displayed with the front showing and smokers are most likely to take cigarettes from packs while looking at the package front (28). The placement of warning labels at the top of the pack, rather than at the bottom, is also likely to increase their visibility and make it more difficult to conceal the warnings in retail displays. After Canada became the first country to introduce large, graphic health warning labels on cigarette packages in 2001, smokers who had read, thought about and discussed the labels were more likely to have quit, made a quit attempt, or reduced their smoking (29). About three in 10 former smokers reported that the labels had motivated them to quit and more than a quarter said that labels helped them remain abstinent (41). In another Canadian study, about a fifth of smokers reported reducing their consumption as a result of seeing the pack warning labels (42). Australia introduced graphic health warning labels in 2006 that caused more than half of smokers to believe that they had an increased risk of dying from smoking-related illness, with 38% feeling motivated to quit (40). Other countries with pictorial warning labels, including Brazil (26), Singapore (43) and Thailand (44), report similar effects on smoking-related behaviour. Graphic warnings also persuade smokers to protect the health of non-smokers by smoking less inside their homes and avoiding smoking near children (43, 45). Health warning labels can be used to promote quit lines Smokers are more likely to reduce tobacco consumption and think about quitting as a result of seeing strong graphic warning labels (25). Providing direct information about cessation services on tobacco packaging, in addition to health warnings, may further motivate smokers to make a quit attempt. Promoting quit lines by including telephone numbers directly on
tobacco packaging raises awareness of the warning labels makes them more believable of other tobacco control measures such as availability of quit line services(46),and the than general warnings and that pictorial establishing smoke-free environments.It experience of several countries shows that it warnings are effective in making youth think is important for national tobacco control increases calls by smokers who are seeking about the health dangers of smoking and programmes to monitor compliance with assistance to quit(46). about reducing consumption (49-51). warning labelling requirements,as tobacco companies in some countries do not follow regulations even when enacted with force Youth respond to Governments benefit from of law (55). warning labels warning labels Youth respond to graphic health warning Warning labels on tobacco packaging can Health warnings in many labels similarly to adults(16).Graphic be implemented at virtually no cost to countries can be made much warning labels are more likely to prevent government(28,32).In general,warning stronger adolescents from initiating smoking(47) labels are overwhelmingly supported by or,if they are already smokers,to think the public,often with levels of support at Many countries,especially low-and middle- about cutting down or quitting(48). 85-90%or higher (52-54),and even most income countries,have health warning Studies of children and adolescents find smokers support labelling requirements. labels that are ineffective,and some do that mentioning specific diseases on health Warnings also help gain public acceptance not mandate any warnings at all.In many In general,warning labels are overwhelmingly supported by the public,often with levels of support at 85-90%or higher, and even most smokers support labelling requirements. WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC,2011 25
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2011 25 tobacco packaging raises awareness of the availability of quit line services (46), and the experience of several countries shows that it increases calls by smokers who are seeking assistance to quit (46). Youth respond to warning labels Youth respond to graphic health warning labels similarly to adults (16). Graphic warning labels are more likely to prevent adolescents from initiating smoking (47) or, if they are already smokers, to think about cutting down or quitting (48). Studies of children and adolescents find that mentioning specific diseases on health warning labels makes them more believable than general warnings and that pictorial warnings are effective in making youth think about the health dangers of smoking and about reducing consumption (49–51). Governments benefit from warning labels Warning labels on tobacco packaging can be implemented at virtually no cost to government (28, 32). In general, warning labels are overwhelmingly supported by the public, often with levels of support at 85–90% or higher (52–54), and even most smokers support labelling requirements. Warnings also help gain public acceptance of other tobacco control measures such as establishing smoke-free environments. It is important for national tobacco control programmes to monitor compliance with warning labelling requirements, as tobacco companies in some countries do not follow regulations even when enacted with force of law (55). Health warnings in many countries can be made much stronger Many countries, especially low- and middleincome countries, have health warning labels that are ineffective, and some do not mandate any warnings at all. In many In general, warning labels are overwhelmingly supported by the public, often with levels of support at 85–90% or higher, and even most smokers support labelling requirements
countries,warnings are weakly worded and cigarettes;these locally marketed products industry is especially resistant to large, vague,provide only general information have typically not been covered by warning graphic pictorial warnings(59).To without mention of specific health risks,and label requirements,and implementation of prevent or delay implementation of health use small-sized print with no pictures.In new labelling guidelines for them has been warnings,the tobacco industry makes some countries,warnings are not printed in inconsistent. various false claims,such as:people a local language. already know the risks of tobacco use; there is no evidence that pictorial warnings Some countries mandate stronger warning Tobacco industry arguments work;large,graphic health warnings labels for manufactured cigarettes than for against effective warning violate tobacco company trademark and other tobacco products or for loose tobacco labels can be countered intellectual property rights;mandating (56),which leads many people to believe warnings is too expensive;more time is that these products are less harmful (57). The tobacco industry regularly fights needed to implement warnings;people This is especially problematic in countries implementation of health warnings who buy tobacco out of packaging(such as where there are high rates of use of local because they are effective in changing single cigarettes)will not see the warnings; tobacco products other than manufactured attitudes about smoking(58),and the graphic warnings demonize tobacco users; Warning labels on tobacco packaging can be implemented at virtually no cost to government. 26 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC,2011
26 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2011 countries, warnings are weakly worded and vague, provide only general information without mention of specific health risks, and use small-sized print with no pictures. In some countries, warnings are not printed in a local language. Some countries mandate stronger warning labels for manufactured cigarettes than for other tobacco products or for loose tobacco (56), which leads many people to believe that these products are less harmful (57). This is especially problematic in countries where there are high rates of use of local tobacco products other than manufactured cigarettes; these locally marketed products have typically not been covered by warning label requirements, and implementation of new labelling guidelines for them has been inconsistent. Tobacco industry arguments against effective warning labels can be countered The tobacco industry regularly fights implementation of health warnings because they are effective in changing attitudes about smoking (58), and the industry is especially resistant to large, graphic pictorial warnings (59). To prevent or delay implementation of health warnings, the tobacco industry makes various false claims, such as: people already know the risks of tobacco use; there is no evidence that pictorial warnings work; large, graphic health warnings violate tobacco company trademark and intellectual property rights; mandating warnings is too expensive; more time is needed to implement warnings; people who buy tobacco out of packaging (such as single cigarettes) will not see the warnings; graphic warnings demonize tobacco users; Warning labels on tobacco packaging can be implemented at virtually no cost to government
and governments should pay for their own WHO FCTC requirements and time;display information on constituents and advertising if they want to issue health recommended guidelines on emissions of tobacco products;and appear in warnings(60,61).These false claims have warning labels the principal language(s)of the country.The often been used to attempt to block health guidelines to Article 11(2)include a number warning legislation,but these spurious Article 11 of the WHO FCTC requires that of other recommendations for health waring arguments can be countered with facts health warning labels on tobacco packaging labels(see the previous chapter for full details about the effectiveness and legality of conform to specified characteristics,induding of WHO FCTC warning label requirements warning labels.In Australia,some tobacco that they be approved by the competent and recommendations). manufacturers have started including cards national authority;cover at least 30%and in cigarette packs that encourage smokers preferably at least 50%of principal pack to complain to the government about display areas;be large,clear,visible and the impending requirements for generic legible and not use misleading terms (e.g. packaging and other tobacco control "light"or "mild");be rotated either by using policies,including smoking bans and multiple warnings that appear concurrently or increased taxes(62). by introducing new warnings after a period of Warning labels that include pictures are most likely to be noticed and rated effective by smokers. WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC,2011 27
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2011 27 and governments should pay for their own advertising if they want to issue health warnings (60, 61). These false claims have often been used to attempt to block health warning legislation, but these spurious arguments can be countered with facts about the effectiveness and legality of warning labels. In Australia, some tobacco manufacturers have started including cards in cigarette packs that encourage smokers to complain to the government about the impending requirements for generic packaging and other tobacco control policies, including smoking bans and increased taxes (62). WHO FCTC requirements and recommended guidelines on warning labels Article 11 of the WHO FCTC requires that health warning labels on tobacco packaging conform to specified characteristics, including that they be approved by the competent national authority; cover at least 30% and preferably at least 50% of principal pack display areas; be large, clear, visible and legible and not use misleading terms (e.g. “light” or “mild”); be rotated either by using multiple warnings that appear concurrently or by introducing new warnings after a period of time; display information on constituents and emissions of tobacco products; and appear in the principal language(s) of the country. The guidelines to Article 11 (2) include a number of other recommendations for health warning labels (see the previous chapter for full details of WHO FCTC warning label requirements and recommendations). Warning labels that include pictures are most likely to be noticed and rated effective by smokers