International Resource Center

Fact Sheet: Tobacco Warning Labels

While many tobacco users generally know that tobacco use is harmful, studies show that most are unaware of the true risks, even in countries in which there has been a great deal of publicity about the health hazards of tobacco.1 As the World Bank has noted, "People's knowledge of the health risks of smoking appears to be partial at best especially in low- and middle-income countries where information about these hazards is limited."2 Smokers tend to be even less aware of the risks of tobacco smoke to others.3

Health warning labels, which should be placed on cigarette and other tobacco product packages as well as all marketing materials, help inform consumers of these dangers. Warning labels are an important component in a national health education program and cost government nothing.

Compelling reasons for implementing strong warning labels include:

• Warning labels are inexpensive for countries to implement because the cost is borne by the companies and not by the government.
• Warning labels detract from the glamour and appeal of cigarettes and help to create an environment where non-smoking is the norm.
• Strong warning labels are essential to counter the attractive and persuasive images tobacco companies have used to market their products for decades.
• Warning labels are unique among tobacco control initiatives because they are delivered at the time of smoking. Virtually all smokers are exposed to warning labels, and pack-a-day smokers are potentially exposed to the warnings over 7,000 times per year.4
• Prominent health warnings and messages on tobacco product packages have been found to lead to an increased awareness of risks and an increased desire to quit,5 even among smoking youth.6 An international comparative study has shown that smokers in countries where a warning depicts a particular health hazard of smoking (e.g., impotence) are much more likely to know about that hazard.7
• Governments worldwide are making tremendous progress in improving tobacco warning labels. The size of warnings is increasing and a growing number of countries require or will soon require picture-based warnings. As countries implement the Framework Convention on Tobacco Control (FCTC), the World Health Organization's international tobacco control treaty, revolutionary improvements to package warnings are being implemented around the world.8

Implementing the Warning Label Provisions of the FCTC

Article 11 of the FCTC states that warning labels should cover at least 50 percent of the principal display areas of the package (i.e. both the front and back), but at a minimum must cover at least 30 percent of the principal display areas. It also requires that the messages be rotated and encourages the use of pictures and pictograms.

Countries should implement the largest package warnings possible in compliance with the requirements and recommendations of the FCTC. Thirteen countries now require that warnings occupy at least 50 percent of the cigarette package, with some requiring warnings that occupy as much as 60 percent of the total package space.

What Makes an Effective Warning Label

To be effective, package warnings must be noticeable, relevant and memorable. They
should also address the concerns of smokers and potential smokers alike.9 There is overwhelming evidence that warnings that contain pictorial as well as verbal elements, are larger, in color, and more comprehensive in content are most effective in communicating the health risks of smoking.10 Warning labels must be large enough to be easily noticed and read.

• Type style and size also must be specified to avoid industry efforts to undermine the impact of the warning.
• Messages should convey both the nature and magnitude of the risks, since studies show smokers underestimate most risks associated with tobacco use. Pictorial warnings are also necessary, particularly in countries with low literacy rates or where research shows smokers are ignoring standard warning labels.
• Warning labels need to be rotated periodically to avoid overexposure. Sample text messages include:
  • CIGARETTES KILL
  • TOBACCO IS ADDICTIVE
  • SMOKING CAUSES HEART DISEASE
  • SMOKING CAUSES 85% OF ALL LUNG CANCER DEATHS
  • TOBACCO SMOKE CAN HARM THOSE AROUND YOU
  • QUITTING REDUCES YOUR CHANCE OF HAVING A HEART ATTACK
• Warning labels should include information for smokers who want to quit about where to find help.
• Warning labels should be applied to all tobacco products, not just cigarettes.11

A Picture Says a Thousand Words

As the saying goes, 'a picture says a thousand words.' Pictures can assist smokers to visualize the nature of a tobacco-caused disease or affliction, and convey health messages to populations with low levels of literacy.12 Twelve countries in North and South America, Asia, the South Pacific, Europe, and the Middle East have finalized laws requiring picture-based warnings. In addition to requiring large text warnings, a European
Union directive gives its 27 member countries the option of adding pictures to the
warnings. Among the many arguments for picture-based warnings:

• Such warnings are likely to reach children, particularly the children of smokers, who are the most vulnerable to starting smoking.
• Pictorial warning labels are accessible to people with low levels of literacy.
• Tobacco product packaging is the ideal tool for communicating with smokers, who are exposed to images printed on packs at least 20 times per day.13

Size Matters

Given tobacco's exceptionally hazardous nature and tobacco companies' failure to
adequately disclose risks, warnings should occupy at least as much area on tobacco
product packaging as any artwork, trademarks or slogans designed to make tobacco
products attractive.14

Australia, New Zealand, Belgium, Switzerland, Finland, Canada, Brazil, Chile, India, Singapore, Thailand, Uruguay and Venezuela all have laws requiring that health messages comprise significant portions of the front and back of the package. Many more countries in diverse regions of the world have passed such laws, which will soon take effect, and many others are considering such laws.

Research on the Effectiveness of Tobacco Warning Labels

The scientific evidence on the effectiveness of warning labels is strong and is growing as more countries introduce stronger labels and evaluate their effectiveness. Evidence from several countries suggests that large warnings with photos are effective in discouraging smoking and increasing public awareness of the health effects of smoking.

According to an international comparative study by Hammond et al., "Large, graphic
warnings on cigarette packages are an effective means of increasing health knowledge among smokers [and] may also help to reduce the disparities in health knowledge by providing low-income smokers with regular access to health information." Hammond and colleagues also found that smokers in countries where a warning depicts a particular health hazard of smoking are much more likely to know about that hazard and smokers who reported noticing warnings were 1.5 to 3 times more likely to believe in each health hazard. 15 This is important because smokers who perceive greater health risk from smoking are more likely to intend to quit and quit smoking successfully.16 This study
provides strong evidence that perhaps the most effective way to convey health risks to smokers is with graphic, large and comprehensive warning labels.

The evidence that warning labels can and do work is solid and extensive, as these
additional examples illustrate:

• A multi-country study published in the March 2007 issue of the American Journal of Preventive Medicine found that larger, more comprehensive warnings are more likely to be noticed and rated as effective by smokers. The study surveyed smokers in the United States, Canada, the United Kingdom and Australia, four countries with widely varying cigarette warnings ranging from large, graphic depictions of disease in Canada to small text warnings on the side of cigarette packs in the U.S. Smokers in Canada were the most likely to report thinking about the health risks of smoking, to stop from having a cigarette, and to think about warnings. Smokers in the U.S. reported the lowest levels of effectiveness for almost every measure recorded.17
• After new, large pictorial warnings were introduced in 2000, 91 percent of Canadian smokers surveyed reported having read the warning labels and demonstrated a thorough knowledge of their content. Further, smokers who read, thought about, and discussed the warning labels in greater depth at baseline were significantly more likely to either quit, attempt to quit, or reduce their smoking at follow-up.18

In Brazil, after the introduction of new picture warnings, 73 percent of smokers approved of them, 54 percent had changed their opinion on the health consequences
of smoking and 67 percent said the new warnings made them want to quit. The impact was particularly strong among less educated, lower income people.19

• The introduction of stronger warning labels in Australia resulted in a 29 percent increase in the percentage of people reporting that they always noticed the warning.20

Industry Arguments and Rebuttals

The tobacco industry has come up with a variety of arguments to undermine warning
label regulations. Some common industry arguments include:

• It is too expensive and technically difficult for us to keep changing the warning labels on tobacco packaging. This claim is simply not true. Tobacco companies routinely change their packaging for promotions and the rollout of brand
  extensions. It is no more difficult or expensive to add new warning labels.
• Larger warnings or the use of pictures will not be more effective than existing warnings. There is overwhelming evidence that the effectiveness of warnings increases with size and that picture-based warnings are far more effective than text-only messages.21 The industry opposes effective warnings precisely because they know that such warnings will contribute to a decrease in sales and profits.
• Smokers already know the health effects of smoking. Studies show that a large proportion of smokers have an inadequate knowledge of the health effects. Many smokers underestimate the health risks. But even those smokers who believe that smoking is associated with health risks may well have an under-appreciation of the severity and magnitude of those risks. Research has shown that an understanding of both risk and severity is necessary to motivate quitting. Picture-based warnings can be effective in conveying severity of those risks.
• Mandatory health warnings constitute an expropriation of the tobacco industry's packages and trademarks. The tobacco industry made the same claim in other countries that have implemented picture-based warnings, but governments
  rejected these claims. And despite these initial claims, no legal challenges have
  since been filed claiming that the warnings violate WTO trade agreements
  respecting intellectual property. Further, implementing provisions in the FCTC
  (such as minimum size for warnings, or the option to use pictures) does not
  infringe international trade laws.
• The warnings 'demonize' smokers and make them feel like outcasts. In fact, the warnings provide smokers with helpful information on the health effects. Most smokers want this information, and certainly want their children to have this information. The tobacco industry is continuing its decades-long strategy of trying to minimize the effectiveness of package warnings. The tobacco industry is no friend of smokers – the tobacco industry kills its best customers.
• If the government wants to put out those messages, it should use billboards or TV commercials. The most important and cost-effective communications medium is
  the package. It has universal reach, and the cost of package warnings is paid for
  by tobacco companies, not government. Further, the combination of a mass media
  campaign and enhanced package warnings is more effective than the mass media
  campaign on its own.

Examples of Warning Labels

Below are some examples of the warning labels used on cigarette packages in Canada
and Australia. "Cigarettes Cause Strokes," "Tobacco Use Can Make You Impotent," and "Cigarettes Are Highly Addictive," have been used on Canada's cigarette packages since 2000. "Smoking Causes Lung Cancer" and "Smoking Causes Mouth and Throat Cancer," have been used on cigarette packages by the Australian Commonwealth Department of Health and Ageing since March 2006.

Endnotes

1 R. Nathan. Model Legislation for Tobacco Control: A Policy Development and Legislative Drafting Manual. (Paris: International Union for Health Promotion and Education, 2004).

2 World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control (Washington, D.C.: World Bank, 1999).

3 R. Nathan, op. cit.

4 D. Hammond, G T. Fong, et al. "Impact of the graphic Canadian warning labels on adult smoking behaviour." Tobacco Control 2003, Vol. 12, No. 4 (December 2003), p. 391-395.

5 R. Nathan, op. cit.

6 G.T. Fong, et al. "Effects of the Canadian Graphic Warning labels Among High School Students: A Quasi-Experimental Longitudinal Survey." (Paper presented at the National Conference on Tobacco or Health, San Francisco, November 2002).

7 D. Hammond, et al. "The effects of warning labels on knowledge about the health risks of smoking: Findings from the International Tobacco Control Policy Evaluation Survey." (Paper presented at the meeting of the Society for Research on Nicotine and Tobacco, Prague, Czech Republic, March 2005).

8 E.J. Strahan, et al. "Enhancing the Effectiveness of Tobacco Package Warning Labels: A Social Psychological Perspective." Tobacco Control, Vol. 11, No. 3 (September 2002), p.183-190.

9 Health Canada. "Regulatory Impact Analysis Statement." Canada Gazette Part II, Vol. 134, No. 15, (July 2000).

10 D. Hammond, G.T. Fong, et al. "Tobacco Control. Vol. 15, Suppl III (June 2006), p.19-25.

11 R. Borland. "Tobacco Health Warnings and Smoking-Related Cognitions and Behaviours." Addiction, Vol. 92, (1997); International Union Against Cancer Tobacco Control Fact Sheet No. 2. "Health Warnings/Messages on Tobacco Products." (1996)

12 Canadian Cancer Society. Confronting the Tobacco Epidemic: Recommendations for Regulations Under the Tobacco Act. (March 1998).

13 Les Etudes de marche Createc, Effectiveness of Health Warning Messages on Cigarette Packages in Informing Less Literate Smokers: Final Report." (Ottawa: Communication Canada, 2003).

14 Framework Convention Alliance, Packaging & Labeling: Recommended Text. (Briefing Paper for INB-3, 2001).

15 Hammond D, Fong GT, McNeill A, Borland R, and Cummings KM. 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_3):iii19-iii25.

16 Romer, D., Jamieson P. The role of perceived risk in starting and stopping smoking. In: Slovic, ed. Smoking: risk, perception, and policy. Thousand Oaks, California: Sage, 2001; 65-80.

17 D. Hammond, G.T. Fong, et al. "Text and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study." American Journal of Preventive Medicine 32 (3), 2007.

18 D. Hammond, G.T. Fong, et al. "Impact of the graphic Canadian warning labels on adult smoking behaviour." Tobacco Control. Vol. 12, No. 4 (December 2003), p.391-395.

19 Costa e Silva, VL. Presentation to EU Commission on enforcement of health warnings in Brazil. Brussels 2002.

20 Borland, R. "Tobacco health warnings and smoking-related cognitions and behaviours" Addiction 1997 Nov.; 92(11)1427-35.

21 G.T. Fong, et al. Quasi-experimental evaluation of the enhancement of warning labels in the United Kingdom: Findings from the International Tobacco Control Policy Evaluation Survey. (Paper presented at the International Congress of Behavioral Medicine, Mainz, Germany, August 2004).