Graphic Pics on Cigarette Packs Are Effective -- But When in US?

Kristin Jenkins

November 04, 2016

Cigarette packages that contain graphic — some would say shocking — photographs of how the story ends for many smokers really work as a smoking deterrent, say US researchers.

Using a tobacco control policy model called SimSmoke, they estimated that photographic warning labels would reduce "status quo" smoking prevalence in the United States by 5% in the short term and by 10% in the long term, when policies are held at 2014 levels before being projected from 2015 to 2065.

Graphic warning labels could prevent more than 652,800 smoking-attributable deaths in the United States over the next 50 years, say the authors, led by David T. Levy, PhD, a professor in the Department of Oncology at Georgetown University Medical Center, Washington, DC, and developer of SimSmoke.

"There is a direct association between these warnings and increased smoking cessation and reduced smoking initiation and prevalence that would lead to significant reduction of death and morbidity, as well as medical cost," they write in a report published online November 3 in Tobacco Control.

Physicians have a duty to...get people to stop smoking in whatever way possible. Dr David T. Levy

"Physicians have a duty to encourage strong and reinforcing policies that get people to stop smoking in whatever way possible," Dr Levy told Medscape Medical News, adding that a soft-sell approach just doesn't work.

"This study makes the point that you really have to hit people over the head to get their attention. You can't just ask patients 'Do you smoke?' and then tell them, 'Well stop.' You have to do something more involving."

For the study, Dr Levy and colleagues reviewed the literature to identify the impact of large, graphic images on cigarette packaging on smoking prevalence, cessation, and initiation. They found evidence that the odds of a quit attempt were 36% higher after implementation of graphic packaging and that in two studies, relapse rates also were reduced.

In addition to estimating the impact on smoking prevalence and smoking-attributable deaths, the SimSmoke model, which has been validated for more than 20 countries, including the United States, was used to estimate the impact of large photographic warning labels on key maternal and child health outcomes.

The device estimated that bigger, more graphic warning labels could avert 46,600 low-birth weight cases, 76,300 preterm births, and 1000 cases of sudden infant death syndrome, say the researchers.

So what's the hold-up in the United States?

In 2009, the Family Smoking Prevention and Tobacco Control Act was signed into law but the tobacco industry quickly got involved, blocking implementation of a 2011 ruling by the US Food and Drug Administration mandating large photographic warning labels on cigarette packages.

Industry lawyers said the ruling violated the cigarette companies' First Amendment commercial speech rights.

As things now stand, US regulations require only side-of-the-package, tiny-text warnings that remain essentially unchanged since the hard-partying 1980s.

"The tobacco industry's brand imagery remains the most prominent feature of cigarette packs seen by consumers, since US regulations only require small, inconspicuous text-only warning labels on the side of the pack," the researchers point out.

A recent US study reported that graphic warning labels on cigarette packages trigger brain activity in areas associated with emotional and cognitive processing, potentially motivating smokers to quit.

Using functional MRI, the investigators of that study found that young adult smokers were significantly more likely to report feeling motivated to quit after viewing graphic warning images than after viewing neutral images.

They also discovered that unlike the neutral images, the graphic warnings elicited responses in four key regions of the brain associated with emotion, cognition, and memory.

Graphic images on cigarette packages appear to be particularly effective in young people, Dr Levy confirmed in an interview, adding that these warnings may also provide support to smokers who have already quit.

"I'm one of the people who believes that there's still a lot of people out there who want to stop smoking, but the ones who have stopped need a lot of reinforcement too. When someone picks up a pack [covered in graphic warnings], it reminds them of why they quit in the first place," Dr Levy commented.

Momentum Building Elswhere

Elsewhere, momentum is building. More than 70 nations have adopted or are considering adopting the World Health Organization's Framework Convention for Tobacco Control to use front- and back of-the-pack photographic warnings.

Australia, Canada, the United Kingdom, and Brazil are among the early adopters.

In 2006, graphic warnings were implemented in Australia. Adult smoking prevalence fell from 21.3% in 2007 to 19% in 2008. Warning labels were implemented in 2008 in the United Kingdom, and smoking prevalence fell by 10% the following year.

Eight years after graphic warning labels on cigarette packaging were implemented in Canada, there was an estimated 12% to 20% relative reduction in smoking prevalence, the researchers point out.

In 2012, the Australian government became the first in the world to enact legislation mandating that all tobacco products be sold in standardized packaging.

Known as "plain packaging," it features large gruesome color photographs of the health damage caused by smoking on 65% of the package, front and back. Written health warnings appear on the top and the side of the pack. There is zero tobacco company presence: no company logos, branding, or promotional text.

Plain packaging in Australia has been a "casebook example of effective tobacco control," Gerard B. Hastings, PhD, and Crawford Moodie, PhD, both from the University of Stirling in the United Kingdom, said in an essay published in the April issue of Tobacco Control.

In countries that fail to introduce similar legislation, the power of cigarette packages as a marketing channel "is only going to increase," they pointed out, adding that "governments which do not act on plain packaging today will have a bigger problem to tackle tomorrow."

In 2013, at the 15th World Conference on Lung Cancer in Sydney, Australia was applauded for its leadership in tobacco control, achieving one of the lowest prevalence rates of cigarette smoking in the world.

"Tobacco restriction is a preventive measure against lung cancer on a population scale," said the Right Honorable Nicola Roxon. "If ever there is a global health challenge, this is it."

In 2012, as Attorney General of Australia, Roxon successfully defended plain packaging legislation in High Court after it was challenged by tobacco giants British American, Philip Morris, Imperial, and Japan Tobacco as being unconstitutional.

"You can take on the tobacco industry and win," she told the packed Sydney audience.

Importantly, the judgment for plain packaging "set an important precedent," she said. It also "knocked on the head any suggestion that the government could be prevented from regulating a dangerous product," she pointed out.

In Canada, legislation to make plain packaging mandatory on all cigarettes being imported or exported took effect on March 21, 2012. Physicians for a Smoke-Free Canada played an instrumental role in lobbying for tobacco reform and photographic warning labels that are now "gazetted" across 75% of each cigarette package, front and back.

Like plain packaging elsewhere, the images act as a dire warning against the health consequences of cigarette smoking. Many feature the stories of real people.

On one cigarette package label, a 47-year-old man sits with an uncovered tracheostomy. The caption reads: "I wish I had never started smoking. I was diagnosed with cancer of the larynx when I was 48. I had to have my vocal cords removed and now I breathe through a hole in my throat. — Leroy."

In another, a bald, skeletal woman lies slack-jawed in a hospital bed, her red fingernails the only remnant of a former life. "This is what dying of lung cancer looks like," the caption reads. "Barb Tarbox died at age 42 of lung cancer caused by cigarette smoking."

Another label warns, "Your kids are sick of your smoking," next to a photo of a small child wearing an oxygen mask. In another, a young girl watches as her mother smokes.

The caption reads: "Children see. Children do."

The study was funded by the National Institute on Drug Abuse and the National Cancer Institute. Coauthor David Hammond, PhD, disclosed that he has served as a paid expert witness on behalf of governments in tobacco litigation, including challenges to health warning regulations. The other coauthors have disclosed no relevant financial relationships.

Tob Control. Published online November 3, 2016. Abstract

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