Best practices in pictorial and graphic health warnings
Syed Ali Wasif Naqvi & Sana Ahmad
This is a thorough examination of global best practices in the implementation of graphic and pictorial health warnings on various tobacco products, including traditional cigarettes, electronic tobacco products (e-cigarettes), and smokeless tobacco products.
It investigates the use of gruesome images as a deterrent to smoking initiation and a motivator for cessation, highlighting the frequency of exposure for individuals consuming a standard daily quantity of cigarettes.
Additionally, it delves into the regulatory landscape concerning heated tobacco products, focusing on Pakistan’s initiative of a 30% textual warning requirement and comparing it with measures adopted by other jurisdictions.
Article 11.1(a) of the WHO Framework Convention on Tobacco Control (FCTC) underscores the commitment of Parties to adopt and implement effective measures, in accordance with their national laws, to prevent tobacco product packaging and labeling from engaging in false, misleading, deceptive, or potentially erroneous promotional practices.
This crucial provision aims to curb the influence of packaging and labeling on consumer perceptions, emphasizing the need for transparency and accuracy in conveying information about tobacco products.
By mandating Parties to enact measures aligned with their national legal frameworks, the article recognizes the diversity of regulatory approaches while ensuring a collective effort to eliminate deceptive marketing strategies. The overarching goal is to safeguard public health by preventing the promotion of tobacco products through any means that could create a false impression, thereby contributing to informed decision-making among consumers and reducing the global burden of tobacco-related harm.
Pakistan has been a signatory to the FCTC for the good part of almost two decades and needs to implement the articles in letter and spirit.
Graphic and pictorial health warnings under Article 11, have emerged as a crucial tool in public health efforts to curb tobacco consumption globally. This article explores the best practices associated with these warnings across different tobacco product categories, emphasizing the impact on smoking initiation and cessation. Many jurisdictions have adopted stringent measures to combat smoking-related health issues through graphic and pictorial health warnings. Australia, for instance, has been a pioneer in this regard, implementing plain packaging coupled with graphic warnings on cigarette packs.
Chapman et. Al., in their 2020 research suggested that such measures significantly influence smokers by delivering impactful visual messages about the health risks associated with smoking. Similarly, Hammond et. al., observed that Canada has also been at the forefront of utilizing explicit graphic imagery to discourage smoking initiation and promote cessation. Their approach involves rotating sets of graphic warnings on cigarette packages, ensuring constant exposure to new visual stimuli. Canada has taken a global lead in placing warning on each individual cigarette, indeed a unique approach.
Moreover, studies indicate that the effectiveness of graphic warnings is not confined to traditional cigarettes but extends to electronic tobacco products and smokeless tobacco as well. Brazil, for instance, has successfully implemented graphic warnings on smokeless tobacco products, contributing to increased awareness and behavioral changes among consumers.
The use of gruesome images on tobacco product packaging has been shown to have a profound impact on smokers. Research conducted in Australia by Dunlop et al., in 2017, indicates that explicit images of smoking-related health consequences, such as lung cancer or cardiovascular diseases, evoke fear and emotional responses, thereby influencing smoking behavior.
The psychological impact of repetitive exposure to such images cannot be overstated, and it serves as a consistent reminder of the risks associated with tobacco use.
For an individual smoking one pack of cigarettes per day, the annual exposure to these images surpasses 7000 instances, creating a continuous reinforcement of the health risks associated with their behavior. This constant reminder is believed to play a pivotal role in discouraging smoking initiation and motivating smokers to contemplate cessation.
While the use of gruesome images on tobacco products is prevalent in many jurisdictions, the specific content and design of these warnings vary. For example, Brazil utilizes explicit images of oral diseases associated with smokeless tobacco, aiming to deter consumers from adopting or continuing such habits. In Canada, graphic warnings include depictions of both short-term and long-term health consequences of smoking, ensuring a comprehensive portrayal of the risks involved.
Research suggests that these graphic warnings have been effective in influencing smoking behavior among Canadians. Australia, known for its pioneering approach to tobacco control, employs graphic warnings depicting the harmful effects of smoking on various organs, reinforcing the health risks associated with tobacco use.
In Japan, where heated tobacco products have gained considerable popularity, graphic warnings are not currently required. Instead, the focus is on textual warnings that convey information about the nicotine content and health risks associated with these products. In contrast, some countries, like Singapore, have taken a more cautious approach by banning the sale and distribution of heated tobacco products altogether. This prohibition reflects concerns about the potential health risks and the need to prevent the re-normalization of tobacco use.
Graphic Health Warning on pack of cigarettes was upgraded to 60% in 2019 from the previous year’s 50% and 40% since 2010. The warning picture and text have not been changed since then. There is an urgent need to upgrade the warning to follow the regional best practices (Nepal at 90%, 80% in Sri Lanka). Pakistan has ample opportunities and examples to learn from and implement global best practices in tobacco control.
Plain packaging has been enforced in Australia (2012), France (2016), the United Kingdom (2016), Norway (2017), Ireland (2017), New Zealand (2018), Saudi Arabia (2019), Turkey (2019), Thailand (2019), Canada (2019), Uruguay (2019), Slovenia (2020), Belgium (2020), Israel (2020), Singapore (2020), the Netherlands (2020), Denmark (2021), and Guernsey (2021). Hungary (2022), Jersey (2022), and Myanmar (2022) are slated for imminent implementation. In practice, three countries, Monaco (from France), Cook Islands (from New Zealand), and Niue (from Australia), have adopted plain packaging for imported products. Formal consideration of plain packaging is ongoing in at least 14 countries: Armenia, Chile, Costa Rica, Finland, Georgia, Iran, Malaysia, Mauritius, Mexico, Nepal, South Korea, South Africa, Spain, and Sri Lanka. These global endeavors to standardize packaging align with public health objectives by minimizing the attractiveness and appeal of tobacco products, discouraging consumption, and mitigating the tobacco-related health burden.
Graphic and pictorial health warnings have become integral components of global tobacco control and WHO MPOWER (Monitoring, Protecting, Offering help to Quit, Warning, Enforcing laws, and Raising Taxes) strategies, influencing smoking initiation and motivating cessation.
The use of gruesome images on tobacco products has proven effective in conveying the severity of health risks associated with smoking. The variability in the content and design of these warnings across jurisdictions underscores the importance of cultural context and regulatory approaches in shaping public health outcomes.
(Syed Ali Wasif Naqvi is the Head of Center for Health Policy and Innovation at the Sustainable Development Policy Institute (SDPI), Islamabad. Sana Ahmed is a tobacco control advocate and works at the Blue Veins, Peshawar).