National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
June 28, 2011 • Volume 8 / Number 13

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Featured Article

New Graphic Tobacco Warning Labels Backed by Research

Two of the nine new graphic warning labels for tobacco products Two of the nine new graphic warning labels for tobacco products

For the first time in more than a quarter century, the look of a pack of cigarettes sold in the United States is changing, thanks to nine new graphic tobacco warning labels released last week by the Food and Drug Administration (FDA). By the fall of 2012, tobacco companies will be required to cover half of the front and back of cigarette packs and cartons with the warnings, which include images of cancer-ridden lungs, rotting teeth, and an infant surrounded by secondhand smoke.

The warnings will also be required to cover 20 percent of all forms of cigarette advertising, including magazine and newspaper ads, brochures, coupons, retail or point-of-sale displays, and Internet advertising. The new warnings are intended to encourage current smokers to quit and to deter nonsmokers, especially young people, from ever taking their first puff.

"The new graphic warning labels will be the toughest and most effective tobacco health warnings in this country's history, and they tell the truth," said Department of Health and Human Services Secretary Kathleen Sebelius at a White House news conference on June 21. "With these warnings, every person who picks up a pack of cigarettes is going to know exactly what risk they're taking."

The Family Smoking Prevention and Tobacco Control Act, signed into law on June 22, 2009, gave the FDA the authority to regulate tobacco products and required the implementation of new graphic health warnings. Last November, the FDA presented 36 proposed images, from which the nine final images were chosen.

"The final nine images were selected based on a number of important criteria," FDA Commissioner Dr. Margaret Hamburg noted at the White House press conference. "We took into account public comment from approximately 1,700 stakeholders, including experts and industry [representatives], some of whom submitted scientific research studies," she explained.

The FDA also conducted a national study to gauge people's response to graphic cigarette health warnings. It was the largest such study ever conducted, involving some 18,000 participants, Dr. Hamburg said.

"We examined how effective the proposed warnings were at communicating the health risks, as well as [their] ability to encourage smokers to quit and [whether] they discourage nonsmokers—particularly kids—from ever wanting to smoke," she added.

In addition to the large color images, every warning will include the number for the national network of smoking cessation quitlines, 1-800-QUIT-NOW, and educational text, such as "cigarettes cause cancer," "cigarettes are addictive," and "tobacco smoke can harm your children."

Evidence Supports New Warnings

More than 30 countries and jurisdictions already require graphic health warnings on tobacco packages. NCI's Tobacco Control Research Branch has funded a number of research projects studying the impact of graphic health warnings as they have been implemented in different countries.

A tobacco sales counter before the new rules take effect Click on this image to see how the new cigarette health warnings will look on packages and advertisements once the new rules take effect.

"Clearly one thing that stands out in our research is that the more gruesome the warning, the greater the effect in being noticed," said Dr. K. Michael Cummings of Roswell Park Cancer Institute, who led one of the research projects supported by NCI. "We also see that warnings that are pictorial and reflect truthfully the harm caused by cigarettes tend to affect knowledge and beliefs about the risk of smoking," he said. "The pictorial warnings certainly do a better job than what we've seen with text-based warnings."

Dr. David Hammond, of the University of Waterloo in Ontario, Canada, another NCI-supported researcher, agreed, saying, "The use of pictures ensures that [the warning labels] can be understood by low-literacy populations, including very young children. The warnings incorporate some of the best practices based on evidence: they are relatively large, they will appear on the front and back of [cigarette] packs, and at least some of the warnings include information that will engage on an emotional level."

Providing information on how to stop smoking directly on cigarette packaging and ads has also demonstrated positive outcomes. "We know from a number of studies that including information that allows smokers to immediately address the health threat posed in the warning messages, such as providing a quitline number or a Web site address where people can get help to stop smoking, will stimulate quit attempts and help [them find] evidence-based support to help them quit," Dr. Cummings said. (In addition to using 1-800-QUIT-NOW, smokers can get help to quit through www.smokefree.gov.)

Dr. Cummings indicated that more research will be needed to understand how often to rotate the warning messages and what new topics should be added to the labels so that consumers are adequately informed about the risks posed by tobacco products. For example, the lack of harm reduction from filtered and low-tar cigarettes and why nicotine addiction is so difficult to overcome are topics that could be considered for future warning labels.

Never Too Late to Quit

Surgeon General Dr. Regina Benjamin appeared at a second news conference to express her support for the new warnings and to provide perspective on the current state of tobacco use in the United States. "With a lot of effort, our nation has reduced tobacco use by half since [the] first Surgeon General's Report in 1964," she said. "However, since 2003, our progress has stalled. One in five adults in the United States continues to smoke. One in five adolescents smokes. Tobacco use remains the leading cause of preventable death in the United States and is responsible for more than 440,000 premature deaths every year."

In addition to loss of life, tobacco use has significant financial consequences. "Almost $200 billion is lost per year in the U.S. alone from increased health care costs and lost productivity costs," said Dr. Lawrence Deyton, director of the FDA Center for Tobacco Products. "We must work together to make tobacco-related death and disease part of America's past, not our future," he added.

"Despite enormous progress, tobacco use remains the leading cause of cancer deaths in the U.S. and is a leading cause of cancer health disparities," added Dr. Robert Croyle, director of NCI's Division of Cancer Control and Population Sciences. "We are very enthusiastic about the potential for the new graphic health warnings to contribute to reducing our nation's tobacco burden."

Quitting at any age and at any time is beneficial. It's never too late to quit, but the sooner you do the better.

—Dr. Regina Benjamin, U.S. Surgeon General

Dr. Benjamin encouraged smokers who want to quit to consult their doctors. Patients who are advised by their doctors have a 66 percent higher success rate, she explained. When smokers quit, the risk of heart disease drops sharply after just 1 year, and the risk of stroke falls to about the same as a nonsmoker's after 2 to 5 years. Risk of cancer of the mouth, throat, esophagus, and bladder are cut in half after 5 years, and risk of dying of lung cancer drops by half after 10 years.

"Quitting at any age and at any time is beneficial," said Dr. Benjamin. "It's never too late to quit, but the sooner you do the better."

A Long-Term Commitment

One concern about the new warning labels is the potential for consumers to become desensitized to the images and the associated health warnings. Dr. Hamburg stated that the FDA will regularly evaluate the success of the images and make changes as necessary. Any future changes will be proposed based on research and evaluation and through rulemaking that includes public notice and the opportunity for public comment.

In addition to updating the cigarette warning labels, regulators may want to consider a more comprehensive public education campaign on tobacco, suggested Dr. Hammond. He noted that increasing taxes and other policies that raise the price of cigarettes also reduce tobacco use.

When the time comes to improve the next generation of cigarette labels, the United States may want to look to countries like Canada or Australia, Dr. Hammond added. Graphic warnings have appeared on cigarette packs in Canada for almost a decade, and, beginning next year, the Australian government will require all cigarettes to be sold in "plain packages"—packages stripped of colors or symbols with the exception of the brand name written in a standard font.

"Given that tobacco use remains the leading cause of cancer deaths in the United States, NCI needs to maintain this commitment to tobacco cessation and control research over the long term if the country is to significantly reduce the cancer burden," said Dr. Hammond.

Jennifer Crawford

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