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Tobacco Pack Health Warnings: A Synthesis and Review of the Evidence

Posted 2:42pm Thu, 26/02/2009 by admin

Tobacco Pack Health Warnings: A Synthesis and Review of the Evidence

The content of this test document is based on information from the review of tobacco labels found at http://www.tobaccolabels.org/ but the organisation has been changed to reflect the purpose of this site, and the current version contains some evidence not covered in that review.

The document is intended to provide evidence that policy makers and other practitioners can use to prepare arguments for placing health warnings on tobacco packaging. Virtually all the research has been done on tobacco packs, but much of the evidence can be generalised to other forms of tobacco packaging.

The document is organised around two major themes:

A. What Can Health Warnings do (what effects can they have) ?, and

B. How do they work (what influences their effectiveness) ?

Part A: What can health warnings do? What effects can they have?

Summary of Effects

Warnings are a key, low-cost channel for informing people about the harms of smoking.
Warnings increase knowledge about harms of smoking.
Warnings lead smokers to think about the risks of smoking and to think about quitting, and these effects, in turn, are associated with future quit attempts.
Changing warnings regularly leads to increases in impact and salience.
Pictorial warnings are more effective than text-only warnings, probably because they are more emotionally arousing and present the harms of smoking in vivid and memorable ways.
Larger warnings are more effective.
Impact of warnings may be stronger in low-/middle-income countries, where there are fewer other sources of information about the harms of smoking.

Can they improve knowledge?

Tobacco pack health warnings increase both knowledge of the harms they warn about, and lead to people thinking more about those harms. Thus, they not only increase knowledge, they also increase the salience of that knowledge

A study of health knowledge and warning labels in Canada, the US, Australia, and the UK in 2002 demonstrated that a large proportion of smokers have inadequate knowledge of the harms of smoking: more than a quarter of smokers did not believe that smoking causes stroke, and fewer than half of smokers believed that smoking causes impotence. Knowledge of health effects was strongest among smokers in Canada, the only country that had pictorial warnings on 50% of the front and 50% of the back of the pack, and weakest among US smokers, where text warnings appear only on the side of the pack. In Canada, where health warnings include the message that smoking causes impotence, almost twice as many smokers (60%) were aware of this health effect compared to smokers from the US (34%), UK (36%), and Australia (36%), where this health outcome was not present in their text labels.¹

Other research showed that Canadian and Australian graphic warnings stimulated more thoughts about the health risks of smoking, than did UK text-based warnings.^{2, 3}

A further study found that Canadian smokers are also more likely than Mexican smokers to know that smoking causes stroke, impotence, and mouth cancer, as these smoking-related health outcomes are included on Canadian warning labels but not on the Mexican ones.⁴

1. Hammond D, Fong GT, McNeill A, Borland R, Cummings KM. 2006. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control 2006;15 Suppl III):iii19–iii25.

2. Hammond D, Fong GT, Borland R, Cummings M, McNeill A, Driezen P. 2007. Text and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study. Am J Prev Med. 32(3):210-217.

3. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong H-H, Hosking W, Hastings G, Thrasher J and McNeill A (2009) Impact of Graphic and Text Warnings on Cigarette Packs: Findings from Four Countries over Five Years, Tobacco Control; http://static.mgnetwork.com/rtd/pdfs/20090711_toba2.pdf

4. Thrasher JF, Hammond D, Fong GT, Arillo-Santillán E. 2007. Smokers’ reactions to cigarette package warnings with graphic imagery and with only text: A comparison of Mexico and Canada. Salud Pública de México, 49 (SuppI).

Can they help keep the harms of smoking "top of mind"?

There is no doubt that graphic health warnings are most effective at keeping the harms of smoking "top of mind". However, the section mentioning "wear out" needs to be kept in mind. The focus of the warnings (i.e. the particular harm/damage) needs to be changed, as does the message and the picture. This way the content is kept fresh¹.

1. Hammond D. Tobacco Labelling and Packaging Toolkit: A Guide to FCTC Article 11. Chapter 1, P20 at: http://www.tobaccolabels.ca/tobaccolab

Can health warnings stimulate quitting?

Tobacco pack health warnings certainly affect thoughts and behaviour that we know are associated with quitting; especially taking steps to avoid viewing the warnings (particularly graphic warnings), and making calls to telephone quit lines.

Evidence from surveys suggests that health warnings can promote smoking cessation among adults and youths, and that larger pictorial warnings are most effective in doing so.¹ In at least two cases, longitudinal studies have demonstrated an association between reading and thinking about health warnings and subsequent cessation behaviour.^2,3 Large pictorial warnings increase knowledge of the harms of smoking, thoughts about the health risks, and behaviours (avoiding the warnings, forgoing a cigarette) that can then motivate intentions to quit, and then quit attempts. Smokers report that large comprehensive warnings have reduced their consumption levels, increased their likelihood of quitting, increased their motivation to quit, and increased the likelihood of remaining abstinent following a quit attempt. ^4,5,6,7,8,9 Additional evidence that health warnings can promote smoking cessation comes from studies conducted in Brazil, the UK, the Netherlands, and Australia showing significant increases in call volumes to quit lines after contact information was included in package warnings.^{1, 10}

The introduction of pictorial warnings in Australia resulted in an increase in noticing and reading of warning labels, thinking about the health risks and quitting, reporting that the labels had made them forgo a cigarette they were about to smoke, and avoiding warning labels, plus the new graphic warnings led to a greater increase in avoiding warning labels than did the text-only warnings in the UK (2004) .¹¹ It has been established that all these outcomes are associated with increases in quitting.¹²

1. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong H-H, Hosking W, Hastings G, Thrasher J and McNeill A (2009) Impact of Graphic and Text Warnings on Cigarette Packs: Findings from Four Countries over Five Years, http://static.mgnetwork.com/rtd/pdfs/20090711_toba2.pdf

2. Hammond D, Fong GT, McDonald P, Cameron R, Brown SK (2003) Impact of graphic Canadian warning labels on adult smoking behaviour. Tobacco Control. 12: 391-395

3. White V, Webster B, Wakefield M. (2008) Do graphic health warning labels have an impact on adolescents’ smoking-related beliefs and behaviours? Addiction. 103(9):1562-71.

4. Health Canada (2005). The Health effects of tobacco and health warning messages on cigarette packages—Survey of adults and adults smokers: Wave 9 surveys. Prepared by Environics Research Group;January, 2005

5. O'Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P. (2006) Reactions of young adult smokers to warning labels on cigarette packages. Am J Prev Med 30(6): 467-73.

6. Willemsen MC. (2005) The new EU cigarette health warnings benefit smokers who want to quit the habit: results from the Dutch Continuous Survey of Smoking Habits. Eur J Public Health. 15(4): 389-92.

7. Canadian Cancer Society Evaluation of New Warnings on Cigarette Packages (2001). Prepared by: Environics, Focus Canada, 2001-3.

8. Hill D. (1988) New cigarette-packet warnings: are they getting through? Med J Aust. 148: 478-480.

9. Cavalcante TM. Labelling and Packaging in Brazil National Cancer Institute, Health Ministry of Brazil; World Health Organiziation. Available at: http://www.who.int/tobacco/training/success_stories/en/best_practices_brazil_labelling.pdf

10. Impact on the Australian Quitline of New Graphic Cigarette Pack Warnings Including the Quitline Number (Tob Control - Miller et al.) Australia 2009

11. Hammond D 2009. FCTC Article 11. Chapter 1. Tobacco Labeling Toolkit. Evidence Review.

12. Borland R, Yong H-H, Wilson N, Fong GT, Hammond D, Cummings KM, Hosking W & McNeill A (2009) How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction. 104(4):669-675.

Can they help denormalise smoking?

The evidence on this question is very strong. All tobacco pack health warnings contribute to the denormaslisation of smoking, and graphic warnings are especially effective.

The Evaluation of Australian Graphic Health Warnings concluded that “graphic health warnings ….heightened consumer concern about smoking, and contributed to deglamourising smoking, making it a less desirable behaviour”.¹ More specifically, prominent health warnings can actually undermine a brand’s appeal and the impact of package displays at retail outlets.^2,3,4 Finally, a Quebec (Canada) Superior Court Judge remarked “ Warnings are effective and undermine tobacco companies’ efforts to use cigarette packages as badges associated with a lifestyle”.⁵

1. Evaluation of the Effectiveness of the Graphic Health Warnings on Tobacco Product Packaging 2008 Executive Summary (Government Report). Australia 2009

2. Borland R and Hill D (1997) Initial impact of new Australian tobacco health warnings on knowledge and beliefs. Tob. Control, 6: 317-325

3. Hyland M and Birrell J (1979) Government health warnings and the “boomerang” effect. Psychol. Reports, 44: 643-647

4. Thrasher JF, Rouso MC, Ocampo-Anaya R, Reynales-Shigematsu LM, Arillo-Santillan E, Hernandez-Avila M (2007). Estimating the impact of different cigarette package warning label policies: The auction method. Addict. Behav. 32(12):2916-25

5. JTI-MacDonald Inc. c. Procureure Générale du Canada (2002) C.S. p42

Can they prevent relapse?

In so far as relapse is concerned, there is really only anecdotal evidence, plus retrospective reports of smokers saying the warnings help. For example, in an evaluation of Australian Graphic Health Warnings, 35% of long-term ex-smokers said that the warnings had "helped them to stay quit", and many participants in group discussions felt that the pictures helped deglamorise smoking and helped reinforce the decision of quitters to stay quit.¹ Among recent quitters, 69% nominated a specific picture and its associated health warning as “most effective” at discouraging smoking. The most popular were “smoking causes throat and mouth cancer” (21%), “Smoking causes lung cancer” (14%), “smoking causes peripheral vascular disease” (10%), and “smoking harms unborn babies” (9%). However, it is difficult studying effects on quitters because one needs to control for exposure to packs, a likely determinant of relapse.

1. Australian Government (2008) Evaluation of the Effectiveness of the Graphic Health Warnings on Tobacco Product Packaging. Department of Health and Ageing.

Can they help prevent uptake/initiation of smoking?

Health warnings employing graphic pictures appear to be effective at dissuading young people from initiating smoking.

More than 90% of Canadian youth agree that picture warnings on Canadian packages have provided them with important information about the health effects of smoking cigarettes, are accurate, and make smoking seem less attractive.¹ Other national surveys of Canadian youth suggest similar levels of support and self-reported impact.²

A recent longitudinal evaluation of pictorial warnings among Australian school children found that students were more likely to read, attend to, think about, and talk about health warnings after the pictorial warnings were implemented in 2006.³ In addition, experimental and established smokers were more likely to think about quitting and forgo cigarettes, while intention to smoke was lower among those students who had talked about the warning labels and had forgone cigarettes.

1. Health Canada. The Health effects of tobacco and health warning messages on cigarette packages—Survey of adults and adults smokers: Wave 9 surveys. Prepared by Environics Research Group; January, 2005.

2. Brown KS, Diener A, Ahmed R, Hammond D. Survey Methods. In: 2002 Youth Smoking Survey Technical Report. 2005. Health Canada, Ottawa. http://www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/yssetj-2002/index_e.html

3. White V, Webster B, Wakefield M. (2008) Do graphic health warning labels have an impact on adolescents’ smoking-related beliefs and behaviours? Addiction. 103(9):1562-71.

Can they have adverse effects, and if so, when and how to minimise?

All the available evidence indicates that there are no significant adverse effects, even from the strongest and most graphic health warnings.

First of all, there has been a high level of public acceptance of health warnings, even the most graphic.^1,2,3 The graphic warnings were criticised on the basis that they could cause defensive reactions among smokers and lessen the likelihood of them quitting.⁴ There is no doubt they do cause strong emotional reactions^{5, 6}, but strong emotional reactions are associated with increased effectiveness of warnings⁵ and adolescents displayed more favourable attitudes toward messages that graphically depicted the costs of smoking as opposed to the gains of not-smoking, and those only exposed to the costs messages had lower intentions of smoking in the future. ⁶ It is also important that smokers who develop strategies to hide the warnings are more inclined to make quitting attempts, rather than “tune out”.^7,8

A qualitative Canadian study⁹ found that “Participants in all groups consistently expected or wanted to be shocked by health warning messages, or emotionally affected in some way. Even if the feelings generated were unpleasant ones to tolerate, such as disgust, fear, sadness or worry, the emotional impact of a warning appeared to predict its ability to inform and/or motivate thoughts of quitting…... When a strong emotion generated by a HWM was supported by factual information, that was the best combination possible”. Overview of Findings, p.3

1. Hammond D, Fong GT, McDonald P, Brown, KS, Cameron R. Graphic Canadian warning labels and adverse outcomes: evidence from Canadian smokers. Am J Public Health 2004; 94 (8): 1442-45.

2. Environics Research Group. Canadian adult and youth opinions on the sizing of health warning messages. Environics Research Group Limited, 1999.

3. Borland R, Hill, D. The path to Australia's tobacco health warnings. Addiction 1997; 92: 1151-1157.

4. Ruiter RAC, Kok G. Saying is not (always) doing: cigarette warning labels are useless. Eur J Public Health 2005;15:329

5. Hammond D, Fong GT, McDonald P, Brown, KS, Cameron R. Graphic Canadian warning labels and adverse outcomes: evidence from Canadian smokers. Am J Public Health 2004; 94 (8): 1442-45.

6. Nascimento BEM, Oliveira L, Vieira AS, Joffily M, Gleiser S, Pereira MG, Cavalcante T, Volchan E. Avoidance of smoking: the impact of warning in Brazil. Tob. Control 2008;17;405-409.

7. Goodall C, Appiah O. Adolescents' perceptions of Canadian cigarette package warning labels: Investigating the effects of message framing. Health Communication 2008; 23: 117–127.

8. Borland R, Yong H-H, Wilson N, Fong GT, Hammond D, Cummings KM, Hosking W & McNeill A (2009) How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction. 104(4):669-675.

9. Les Etudes de Marche Createc. Final Report: Qualitative testing of health warnings messages. Prepared for the Tobacco Control Programme Health Canada, June 2006

Can health warnings wear out ?

It seems feasible that wear out could occur, and there is evidence to suggest that it does. The Australian Government evaluation¹ concluded that "there is evidence of wear out and some smokers have suggested the need to update some of the health warnings with new graphic images to strengthen their effectiveness and possibly changing warning design aspects to revitalise the strategy" (P21)

1. Evaluation of the Effectiveness of the Graphic Health Warnings on Tobacco Product Packaging 2008 Executive Summary (Government Report) .

Part B: How do they work? What influences their effectiveness

1. Recommendations for the strongest possible warning systems.

2. Does size matter ?

3. Does adding graphic images increase the power of health warnings ?

4. Does position on the pack matter ?

5. How do we minimise wear out ?

6. Is it important for regulators to specify the form and content of health warnings ?

7. Should there be a single warning or a set ?

- How many warnings should there be ?

- How should they be rotated ?

8. What kinds of content should they have ?

- Is it always necessary to focus on harms ?

- Does information about quitting add to their effectiveness ?

- Should they provide access points for further advice ?

- Should they include information on toxin yields ?

9. What strategies have been used by the tobacco industry to minimise the effectiveness of warnings ?

Recommendations for the strongest possible warning systems.

The most effective warning systems use warnings that:

Are large (i.e. 50% or more of the available display area).
Are on the front of the pack, in packs which have a distinguishable front and back.
Are located in the upper portion of the pack.
Present graphic pictures of the harms of smoking (e.g. graphic pictures of the effects of diseases like cancer of the mouth, or gangrene). You will find a collection of pictorial warnings from around the world here
Combine graphic pictures of disease with supportive quitting information.
Are regularly updated to avoid wear out

Examples of Best Practice Packs from Australia

Evaluation of the Effectiveness of the Graphic Health Warnings on Tobacco Product Packaging 2008 Executive Summary (Government Report) Australia 2009

FCTC Article 11 Tobacco Warning Labels: Evidence and Recommendations from the ITC project (ITC Report) Canada 2009

Survey on Tobacco Analytic Report (Gallup Organisation - EC report) European Union 2009

Health Warnings Report (German Cancer Research Centre Report) (German) Germany 2009

Health Warnings on Tobacco Products Report (Government Report) Brazil 2008

Consumer Research on the Size of Health Warning Messages (CDN Adults) (Government Report) Canada 2008

Consumer Research on the Size of Health Warning Messages (CDN Youth) (Government Report) Canada 2008

Health Canada Research on Warning Message Size 2008 (Highlights of Government Report) Canada 2008

Labelling and Packaging in Brazil (WHO report - Cavalcante) Brazil 2007

Canada's Tobacco Package Label or Warning System "Telling the Truth" about Tobacco Product Risks (WHO Report - Mahood) Canada 2007

Testing of Bilingual Health Warning Notices for Tobacco Industry Print Advertising (Government Report) Canada 2007

Testing of Mock-ups of Health Warning Messages and Warning Notices on Tobacco Product Advertisements for Smokeless Tobacco (Government Report) Canada 2007

European Community Directive on Packaging and Labelling of Tobacco Products (WHO report - Joussens) European Union 2007

Thailand Country Report on Labelling and Packaging (WHO Report - Chitanondh) Thailand 2007

Consultation on the Introduction of Picture Warnings on Tobacco Packs (Government Report) United Kingdom 2007

The Introduction of Picture Warnings on Tobacco Packs (Government Report) United Kingdom 2007

Colour Photos on Tobacco Packages Experience in Other Countries (Government Report) Netherlands 2007

Illustration-Based Health Information Messages Concept Testing (HC Government Report) Canada 2006

Pictorial Health Warnings a Review of Research Evidence (Government Report) New Zealand 2006

2. Research Papers (Hot links)

Impact on the Australian Quitline of New Graphic Cigarette Pack Warnings Including the Quitline Number (Tob Control - Miller et al.) Australia 2009

Smokers Responses Toward Cigarette Pack Warning Labels in Predicting Quit Intention, Stage of Change, and Self-efficacy (Fathelrahman et al, Nic Tob Res) Malaysia 2009

New Graphic Warnings Encourage Registrations With the Quitline (Tob Control, Li and Grigg) New Zealand 2009

Do Graphic Health Warning Labels Have an Impact on Adolescents’ Smoking-related Beliefs and Behaviours? (Addiction - White et al.) Australia 2008

Avoidance of Smoking: The Impact of Warning Labels in Brazil (Tobacco Control - Nascimento et al.) Brazil 2008

Adolescents' Perceptions of Canadian Cigarette Package Warning Labels: Investigating the Effects of Message Framing (Health Commun - Goodall and Appiah) Canada 2008

Potential Effectiveness of Health Warning Labels among Employees in Thailand(J Med Assoc Thai - Silpasuwan et al.) Thailand 2008

Effects of Including a Graphic Warning Label in Advertisements...Persuasion and Policy (Jour of Appl Soc Psych - Stark et al.) USA 2008

Text and Graphic Warnings on Cigarette Packages ITC-4 (Am J Prev Med - Hammond et al.) Australia 2007

Smokers Reactions to Cigarette Package Warnings With Graphic Imagery and With Only Text Comparison Between Mex and Can (Salud Publ de Mexico - Thrasher et al.) Canada 2007

Text and Graphic Warnings on Cigarette Packages ITC-4 study (Am Jour Prev Med - Hammond et al.) Canada 2007

The Effectiveness of Text and Graphic Warnings on Cigarette Packages (Zeitschrift für Sozialpsychologie - Petersen, Lieder)(German) Germany 2007

Estimating the Impact of Different Cigarette Package Warning Label Policies: The Auction Method (Addictive Behaviors - Thrasher et al.) Mexico 2007

Visual Attention to Health Warnings in Tobacco Advertisements An Eye-Tracking Research Between Smokers and Nonsmokers (Studia Psychologica - Crespo et al.) Spain 2007

Text and Graphic Warnings on Cigarette Packages ITC-4 Study (Am Jour Prev Med - Hammond et al.) United Kingdom 2007

UK Government to Put Graphic Warnings on Tobacco Products (BMJ - Davis) United Kingdom 2007

Text and Graphic Warnings on Cigarette Packages ITC-4 Study (Am Jour Prev Med - Hammond et al.) USA 2007

The Impact and Acceptability of Canadian-style Cigarette Warning Labels Among U.S. Smokers and Nonsmokers (Nic and Tob Research - Peters et al.) USA 2007

Worth More Than a Thousand Words Picture-Based Tobacco Warning Labels and Language Rights in the U.S. (Report - Browne et al.) (Spanish) USA 2007

Worth More Than a Thousand Words Picture-Based Tobacco Warning Labels and Language Rights in the U.S (Report - Browne et al.)(Chinese) USA 2007

Worth More Than a Thousand Words Picture-Based Tobacco Warning Labels and Language Rights in the U.S (Report - Browne et al.)(English) USA 2007

Effectiveness of Cigarette Warning Labels in Informing Smokers About the Risks of Smoking ITC-4 (Tobacco Control - Hammond et al.) Australia 2006

Tobacco Industry Smoking Prevention Advertisements' Impact on Youth Motivation for Smoking in the Future Australia 2006

Canada a New Angle on Packs (Tobacco Control - Hammond) Canada 2006

Effectiveness of Cigarette Warning Labels in Informing Smokers About The Risks of Smoking ITC-4 Study (Tobacco Control - Hammond et al.) Canada 2006

Qualitative Testing of Health Warnings Messages (Government Report) Canada 2006

Tobacco Denormalization and Industry Beliefs (Am Jour Prev Med - Hammond et al.) Canada 2006

Warning Messages in Cigarettes Packages a Comparative Linguistic-Discursive (Report - Sabaj) (Spanish) Chile 2006

Showing Leads to Doing Graphic Cigarette Warning Labels Are An Effective Public Health Policy (Eur Jour Publ Jealth editorial - Hammond) European Union 2006

Response to Hammond et al. Showing Leads to Doing But Doing What The Need for Experimental Pilot-Testing (Editorial - Ruiter, Kok) Netherlands 2006

Effectiveness of Cigarette Warning Labels in Informing Smokers About the Risks of Smoking ITC-4 (Tobacco Control - Hammond et al.) United Kingdom 2006

Tobacco Denormalization and Industry Beliefs Among Smokers from Four Countries (Am Jour of Prev Med - Hammond et al.) United Kingdom 2006

Effectiveness of Cigarette Warning Labels in Informing Smokers About the Risks of Smoking ITC-4 Study (Tob Control - Hammond et al.) USA 2006

Reactions of Young Adult Smokers to Warning Labels on Cigarette Packages (Am Jour Prev Med - O'Hegarty et al.) USA 2006

Tobacco Denormalization and Industry Beliefs Among Smokers from Four Countries (Am Jour Prev Med - Hammond et al.) USA 2006

Why is Such a Smart Person Like You Smoking Using Self-Affirmation to Reduce Defensiveness... (Jour Appl Biobehavior Research - Dillard et al.) USA 2006

References

Reference Number	Title	Link	Author
2	The impact of cigarette package design on perceptions of risk	Abstract	David Hammond, Carla Parkinson
3	Australian Government Evaluation of Graphic Health Warnings: Full Report	hw-eval-full-report.pdf	Smokey the Bear
4	Response of mass media, tobacco industry and smokers to the introduction of graphic cigarette pack warnings in Australia	Abstract	Miller CL, Hill DJ, Quester PG, Hiller JE

Tobacco Control Intelligence System

Tobacco Pack Health Warnings: A Synthesis and Review of the Evidence