WellnessAre graphic warning labels effective at keeping people from buying cigarettes?
Hopes&Fears talked to several public health advocates.
Smoking prevention has become a massive international health policy concern; the World Health Organization’s Framework Convention on Tobacco Control has affected public health policies for 90% of the world’s population, with nearly 20% of the world’s population (about 1.4 billion people) educated by its strictest measures.
Graphic warning labels—those incredibly gross visuals displaying the worst possible effects of smoking—are perhaps the most recognized anti-smoking strategy deployed by anti-tobacco initiatives, which claim that the visual impact forces smokers to face the truth about their habit and perhaps even keep people from buying cigarettes in the first place. From gruesome image of decaying teeth, to blackened lungs, or even autopsied corpses and gangrened limbs, the labels rely on visceral reaction to help educate consumers about the real dangers of smoking.
But after New York City’s Independent Budget Office released a report this month saying that smoking rates in the city have actually risen despite implementing the highest tobacco tax rates in the United States and a six-year old law requiring cigarette retailers to display graphic warning posters at the cash register, we couldn’t help but wonder: do the graphic warning labels really work? How effective have they been?
Wearing out the warning
Geoffrey T. Fong is a Principal Investigator at the Canada-based International Tobacco Control Policy Evaluation Project (the ITC Project), which has been conducting large scale evaluation studies of tobacco control policies for 13 years. According to Fong, graphic warnings have been incredibly effective. “We have found that the introduction of graphic warnings has led to more knowledge about the specific health harms of cigarettes depicted on the warnings,” Fong tells Hopes&Fears. “Moreover, smokers report that they are more likely to think about these health harms and report that the graphic warnings are more likely to make them think about quitting.”
According to the ITC Project the impact is widespread, with similar findings across the board in countries that implement graphic warning labels.
“Our findings arise from large representative samples of smokers in each country, and we do a longitudinal study, which means that we come back to the same people before and the warnings [are implemented],” Fong explains. This, notes, is in contrast to countries that still rely on text-only warnings, like China.
In fact, text-based warning labels appear to have very little impact on smokers at all. Mark Gottlieb, Executive Director of the US Public Health Advocacy Institute, confirms that, in addition to content, size and placement matter just as much. “Graphic warnings are a proven way to communicate with smokers and deter would-be smokers—the larger and more graphic, the better,” he says. “In a meta-analysis of over 100 cigarette health warning studies found that the impact of health warnings depends upon their size and design.”
But could the lack of effectiveness of the old “Surgeon General’s warning” simply have been rooted in fatigue of messaging? And if so, could this not impact the effectiveness of graphic warning labels over time as well? “Absolutely,” says Fong. “We have demonstrated in our research that over time, warning labels, like any communication—TV ads, for example—have lowered impact.” It’s a sensation called “wear-out,” and requires a change in messaging every two to three years.
Mortality Attributed to Tobacco
International tobacco-related disease rates:
71% of all lung cancer deaths are attributable to tobacco use
42% of all chronic obstructive pulmonary disease are attributable to tobacco use
No simple way
Some believe that warnings have no effect at all, saying that they don’t really expose consumers to information they don’t already know. “[The United States] have had warnings on cigarette packets since the 1960s, y,et the rates of smoking have risen in this world full of cigarette warning label,” economist W. Kip Viscusi explains to Hopes&Fears. “And graphic warnings don’t really add much other than making the cigarette packs uglier.” In fact, some see graphic labels a solvable inconvenience; Australia for instance has developed a hefty market for cigarette containers that simply block the warning images.
Given that warning labels only stay effective for limited periods of time even when they do seem to work, what can governments do to help fight tobacco use? Gottlieb proposes a widespread adoption of raising the minimum age of tobacco sale to 21, as NYC implemented last year. “Because nearly 90% of smokers became addicted before the age of 21, this may be a very effective strategy,” Gottlieb explains. A 2015 report released by the US Institute of Medicine found that raising the legal tobacco purchasing age to 21 lowers adolescent initiation rates, as those who can legally obtain tobacco are less likely to be in the same social circles as high school students.
Further, Gottlieb notes that the FDA has the power to lower permitted nicotene content in tobacco products to non-addictive levels, or can even ban places where cigarettes can be sold. A 2011 Canadian report found that 40% of smokers between the ages of 18-34 would smoke less if they had to travel further to buy cigarettes. The analysis also shows that "proximity of the smoker’s home to a tobacco retailerpredicted smoking cessation," with those living further from a tobacco retailer more likely to maintain smoking cessastion.
"There may not really be a single, 'best' way to get people to stop smoking," Gottlieb stresses. "Australia has introduced plain packaging and eliminated graphic advertising of tobacco products. Legislation is pending in Tasmania such that no person born since January 1, 2000 may ever purchase a tobacco product." Gottlieb believes that this approach, known as “Tobacco-Free Generation," could one day be implemented in the U.S. to help keep people from starting to smoke in the first place.
The top countries in terms of warning size as an average of the front and back
85% of front, 85% of back
75% of front, 90% of back
80% of front, 80% of back
Canada, Nepal, Brunei 75%
75% of front, 75% of back
65% of front, 65% of back
Editor: Gabriella Garcia