David Hammond, Ph.D.
Department of Health Studies and Gerontoloty
University of Waterloo
Waterloo, Ontario, Canada
Every year, smoking kills more than 276,000 men and 142,000 women in the United States - more women currently die from lung cancer than breast cancer. Globally, 5 million people will die from tobacco in 2008, more than tuberculosis, HIV/AIDS and malaria combined. The health burden from tobacco reflects the wide range of smoking-related diseases: causal links have been identified for 10 types of cancer, as well as 18 other diseases. Remarkably, the list of known health risks continues to grow, with cancers of the stomach and acute myeloid leukemia among those most recently identified.
Given the uniquely hazardous nature of tobacco products, tobacco manufacturers and governments bear a responsibility to ensure the highest levels of health knowledge possible among consumers. Yet, how does one communicate the full range and severity of health risks to an increasingly jaded public, most of whom already have a general awareness that smoking is harmful?
The answer, according to an increasing number of countries, is to require that tobacco packages display large, graphic pictures of smoking-related disease. Canada initiated the practice in 2000 by requiring that one of 16 pictorial warnings cover half of the package. Since this time, 15 other countries have also implemented pictorial warnings, with dozens more preparing to do so in the near future.
The content of pictorial warnings is often vivid and sometimes gruesome. For example, Australian packages now carry a graphic picture of a gangrenous foot that covers 90% of the package front. Some have suggested that these warnings may be excessive. The tobacco industry, for example, has actively opposed large picture warnings on the grounds that graphic pictures arouse unnecessary fear among smokers, without providing any more information than text warnings. Research to date paints a different picture. Studies indicate that large, graphic warnings on cigarette packages are an effective means of increasing health knowledge among smokers. Not only do warnings present new information to smokers, but they also provide constant reminders given their frequency of exposure: pack-a-day smokers are potentially exposed to the warnings more than 7,000 times a year. Large warnings are also visible in retail outlets and at the time of purchase.
Comprehensive package warnings do more than list health effects: they help to make these health effects vivid by communicating the severity and personal loss from smoking-related disease. Smokers consistently identify the most provocative, arousing images as the most effective messages. Pictorial warnings in Canada and elsewhere also include supportive messages and concrete information on quitting. Research from health communication and "fear appeals" indicate that the most effective messages are those that both warn and provide supportive "efficacy" information. Indeed, large warnings that also include a toll-free telephone "helpline" have dramatically increased the use of cessation services in places such as Australia, the United Kingdom, Brazil, and the Netherlands.
Large picture warnings also enjoy strong public support, including among smokers. Even in countries such as Canada, where graphic pictures cover half the package, the majority of smokers report a desire for even more health information on their package.
Given their universal reach, health warnings may also help to reduce health disparities. Smokers typically have lower incomes, levels of education, and report lower access to health services; yet package health warnings reach virtually all smokers, regardless of socio-economic status. In addition, text-warnings are completely ineffective among those who with low literacy skills - including young children - whereas pictures can be universally understood. Picture warnings are particularly important in many low and middle-income countries where significant proportions of smokers are illiterate.
Overall, large pictorial health warnings have been shown to be an extremely prominent, cost-effective means of communicating with smokers. In recognition of this evidence, the World Health Organization recently identified comprehensive warnings as among the six key measures required to address the tobacco epidemic. The WHO recommendations carry particular weight in the U.S. where labeling policy has lagged far behind international practice: U.S. health warnings appear in faint print on the side of packages and have not been updated since 1984 - a period of almost 25 years. As a consequence, the U.S. warnings will soon hold the dubious distinction of being the oldest and among the weakest in the world. The result is that consumers continue to receive little information regarding the health effects, ingredients, or toxicants in their tobacco products. Indeed, chocolate bars carry more information about ingredients than cigarette packages.