April 20, 2017

Smoke Screen

Bigger, more graphic, warnings on cigarette packs reduce smoking. But the U.S. tobacco industry is blocking them. The public is not pleased.

What better place to warn people about the dangers of smoking than cigarette packs? Having larger, and more graphic health warnings on cigarette packages can increase people's knowledge of tobacco risks, their interest in quitting and their actual attempts at quitting.

Bigger, flashier warnings are found on packs of cigarettes around the world, but the United States lags far behind many other countries when it comes to public health measures known to reduce smoking and its devastating health outcomes. Deaths from tobacco can be significantly decreased when appropriate labels are used effectively for public health education.

Over 134 countries and jurisdictions required health warning labels on cigarette packages that covered at least 30 percent of the package in 2014. And over 60 countries and jurisdictions required that such labels cover over 50 percent of a cigarette pack, while six countries (including Canada) require that warnings cover 75 percent.

A 2009 act required the FDA to include graphic/pictorial warnings and to increase the size of warnings to 50 percent of the front and back, but industry litigation has prevented this from being implemented to date.

The United States is one of 50 countries that has not implemented either pictorial warnings against smoking or larger warnings on the front and back of cigarette packages.

In the U.S., the warnings are words without pictures, and cover about 10 percent of the package, typically placed on the side. The warnings, initially required in 1965, have not changed in format since 1985. A 2009 act required the FDA to implement changes including graphic/pictorial warnings and to increase the size of warnings to 50 percent of the front and back, but industry litigation has prevented this from being implemented to date. In October, 2016, eight public health and medical groups filed a lawsuit to force FDA compliance.

While research supports the effectiveness of this public health strategy in reducing deaths from tobacco, little has been known about public support for the proposed changes. A study, published in PLoS ONE, was designed to fill this knowledge gap. The University of North Carolina, Chapel Hill researchers set out to measure Americans' support for increases in the size of the cigarette warning labels. They reasoned that if citizens were known to be supportive, law and policy makers might be influenced to strengthen and enforce the 2009 legislation.

They conducted phone interviews of around 5000 individuals and asked about their attitudes towards warning labels that covered 25 percent, 50 percent or 75 percent of the cigarette pack.

Half the participants were women; more than 75 percent were over 25; 68 percent were white; 57 percent had some college education or higher, and 75 percent were above the poverty line. Slightly less than 20 percent of the participants were current smokers.

There was widespread support, even among smokers, for an increase in the size of warning on cigarette packs. Nearly three-quarters of respondents favored warning labels as large as 75 percent of pack size with somewhat more supporting labels of 50 percent. Young adults, women, racial and ethnic minorities and non-smokers were more likely to have favorable attitudes toward larger warning sizes; so were smokers intending to quit.

If larger, pictorial labels were instituted, much of the public would support the action, the authors conclude. They hope their data will encourage legislators to act.

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