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Can pictorial health warnings reduce global tobacco use?

Tobacco pack with image of damaged teeth caused by tobacco Tobacco accounts for more than half a million deaths each year in the EU. In support of this year's World No Tobacco Day, which focuses on decreasing tobacco use by increasing public awareness of its dangers, both the European Commission (EC) and World Health Organisation (WHO) have published reports aimed at revealing how people view tobacco and the importance of packaging in reducing its use. Specifically, the WHO report points to the effectiveness of using images in combination with text as health warnings on tobacco packaging.

Motivating change
In 'Showing the truth, saving lives: the case for pictorial health warnings', the WHO states that effective health warnings, especially those that include pictures, motivate users to quit and to reduce the appeal of tobacco for those who are not yet addicted.

"Health warnings on tobacco packages are a simple, cheap and effective strategy that can vastly reduce tobacco use and save lives," says WHO assistant director-general, Dr Ala Alwan. "But they only work if they communicate the risk. Warnings that include images of the harm that tobacco causes are particularly effective at communicating risk and motivating behavioural changes, such as quitting or reducing tobacco consumption."

At present, 23 WHO jurisdictions, with a combined population of nearly 700 million people, require large graphic health warnings on packaging. Of these, just three are in Europe: Belgium, which brought in legislation in 2006, and Romania and the UK in 2008. Switzerland and Latvia have legislation in place to implement pictorial warnings by 2010. France, Hungary, Ireland, Malta, Poland and Spain plan to introduce pictorials in the near future.  

Picture power
In 2005, the EC created a picture library of 42 graphic images to accompany the mandatory health warnings on tobacco packs and plans to renew the current health warnings in 2010. More than half (55 per cent) of EU citizens believe that adding a colour picture to a text-only health warning strengthens the effectiveness of the message.

The EC has also given the right to use the images to several countries outside the EU and urges all the member states to make use of pictorial warnings.

More than 160 countries have ratified the WHO Framework Convention on Tobacco Control, which commits its parties to require that tobacco products "carry health warnings describing the harmful effects of tobacco use". The Article 11 best-practice guidelines to the treaty stipulate that warnings should be large and clear, appear on both sides of tobacco packages and describe specific illnesses caused by tobacco.

Research demonstrates the importance of packaging to marketing campaigns. Tobacco companies monitor and alter packaging on a regular basis to ensure regular and increasing appeal. Not only is the packaging highly visible, it is a critical link between the product and other forms of promotion. Packaging is gaining in importance as other promotional routes are restricted or removed by law. Attractive displays in retail outlets promote tobacco at the critical moment when the consumer is prepared to buy.

Packaging and branding are particularly important to young people – who are the main source of new customers for tobacco companies. Cigarettes have a high degree of social visibility and users perceive their own personality in the brand image.

Mass media message
Packaging's strengths can, therefore, also be used for communicating public health messages. Health warnings on packaging should be thought of as a mass media campaign, virtually guaranteed to be seen by almost all smokers and many potential smokers. For example, a pack-a-day smoker sees the package at least 7,300 times a year.

In addition, this way of communicating health information is an extremely cost-effective public health measure for governments, as most of the costs (other than those associated with the implementation of government policy) are borne by tobacco companies. Yet only 10 per cent of people worldwide live in countries that require warnings with pictures on tobacco packages.

Specific health education
There is good general awareness of the fact that tobacco harms health in many countries, specific knowledge and perception of risk are far poorer. This is of concern because specific knowledge of risks is more likely to motivate smokers to try to stop. In China, for example, a February 2009 survey showed that only 37 per cent of smokers knew that smoking causes coronary heart disease and only 17 per cent knew that it causes stroke.

Studies carried out after the implementation of pictorial package warnings, using both pictures and text, have shown they are effective at motivating behaviour changes such as stopping smoking or avoiding exposing others to smoke. Young people in particular respond to shocking, realistic images.

Prior to implementing its pictorial warnings, the UK government set up a website for the public to vote on pictures they felt would be most effective, and those that received the most votes were those that most graphically showed the negative health impacts.

Countries that have combined such images with details of where to get help to stop smoking – through a website or telephone number – have seen greater benefits from the campaigns.

Positive impact
WHO recommends that there should be warnings on all main faces of the packaging. The top front part of the pack is considered the best advertising space by tobacco companies.

In some countries, tobacco companies market double packages that open up to reveal additional main faces that do not carry health warnings, so requiring warnings on 'all main faces' helps close this sort of loophole.

The EC-commissioned 'Survey on Tobacco', which took place in December 2008, considers the opinions of people over the age of 15 in each EU country, and Norway. This research reveals that adding a colour picture to a text-only health warning is perceived as effective by more than half of EU citizens: 20 per cent state this would be very effective and 35 per cent think it is somewhat effective.

More than four out of 10 (44 per cent) interviewees perceive pictorial health warnings as more effective than text-only health warnings. The proportion of respondents who think that adding such pictorial messages would be effective ranges from slightly less than four out of 10 respondents in the Czech Republic (37 per cent) and the Netherlands (38 per cent) to three-quarters in Ireland (75 per cent) and Cyprus (74 per cent).

In the three countries where pictorial messages are already in use, Romanian and British respondents are most positive about their effectiveness, with 61 per cent of Romanian and 56 per cent of British respondents saying that such warnings are effective when added to a text-only warning. However, the Belgian respondents are more sceptical, with 12 per cent thinking that adding a colour picture is very effective and 27 per cent, somewhat effective.

Reaching those at risk
Despite the fact that there are many resources available to help governments reduce tobacco usage, 90 per cent of the world's population does not have access to pictorial warnings. In countries where a large proportion of the population is illiterate, such images could be very effective.

The WHO's call to action aims to show governments how best to use pictorial health messages, thereby saving lives, and reducing the burden on health services through tobacco-related illnesses. Through its MPOWER programme – which is a technical assistance package of six tobacco control measures, designed to ensure that even low-income countries can make progress in reducing tobacco use – it hopes to make inroads into the problem but there is still much to do to combat the global threat to health.

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15th July 2009


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