How do you get a smoker to quit?

Science-ish looks at the effectiveness of graphic warning labels

The Statement: “These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit, and prevent children from smoking.” (Kathleen Sebelius, U.S. secretary of health and human services, 06/21/2011)

On Tuesday, the FDA ramped up its war on tobacco by introducing nine new graphic warning labels for cigarette packages. This means that after decades of having only text caveats, America’s smoke packs will feature soot-stained lungs, rotten teeth, cadavers, and crying babies.

Given all the attention paid to labeling, Science-ish wanted to know: how much does packaging matter to smokers? And do non-smokers pay attention to the warnings?

To find out, we called the University of Waterloo’s David Hammond, a global expert on the matter who has published extensively on health warning labels and served as adviser for the World Health Organization (WHO) on tobacco control, helping to create packaging and labeling guidelines for 172 countries.

In a submission to the FDA (PDF), Hammond wrote, “A wide variety of research has demonstrated the effectiveness of using pictures and imagery in health communications. These studies suggest that health warnings with pictures are significantly more likely to draw attention, result in greater information processing, and improve memory for the health message than text-only warnings. Picture warnings also encourage individuals to imagine health consequences and are also more likely to be recalled when an individual is making relevant judgments and decisions.” The evidence also shows that picture-based warnings are more effective than text-only labels as a deterrent for potential new smokers and as a means to getting people to quit.

But though the introduction of graphic warning labels on cigarette packs has resulted in some positive gains (in Canada, for example, youth smoking rates declined after 2001, when we became the first country to add picture-based health warnings to cigarette packs), Hammond cautions, “there is no reliable way to attribute these changes specifically to the warnings rather than other tobacco control measures.”

So why have more than 30 countries followed Canada’s lead in adopting the graphic warnings? Well, they work on some people, and some is better than none, says Hammond. “When you speak to 1,000 or 2,000 smokers that you randomly sample, you get about a third who say they aren’t going to have an impact. And you get three out of ten who say these labels do have an impact. When it’s 30 per cent of almost five million people, that’s huge.”

They also reach children, and those who are illiterate or who don’t speak either official language. “We know a third of former smokers say the warnings help them to stay [non-smokers] by providing a reminder,” added Hammond. And they don’t cost very much. According to Michael Chaiton, assistant professor in tobacco and public health at the University of Toronto, “Money for labeling is marginal compared to other spending.” News reports about leaked Health Canada documents said that the new labels for packs in Canada cost $3.6 million.

If we must use graphic images, then, which images work best? Those that elicit strong emotions, which is why you’ll notice grotesque depictions of diseases linked to smoking and real human subjects instead of cartoons. In his submission to the FDA, Hammond wrote, “Studies in France, Belgium, Romania, Spain, Bulgaria, and the U.K. consistently demonstrated that warnings with hard-hitting images (such as rotten teeth or throat cancer tumours) were rated as most effective.”

Size matters, too. Hammond’s May 31, 2011 review article in Tobacco Control, noted, “The evidence indicates that the impact of health warnings depends upon their size and design: whereas obscure text-only warnings appear to have little impact, prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non-smokers, can increase health knowledge and perceptions of risk and can promote smoking cessation.”

And images must not become stale. Experts recommend that new warnings should be implemented every two to four years in order to continue to be effective, since they have the most impact shortly after they go on the market. This means Canada is long overdue—labels haven’t been changed since 2001—though we may finally see news ones next year. (This year, Health Canada unveiled 16 proposed new warnings that are larger than the current ones. The Standing Committee on Health’s report on the new regulations, tabled in the House of Commons this week, recommended that the Government enact the proposed warnings. The House of Commons as a whole agreed with the decision, which means the new imagery may grace cigarette packs by 2012.)

As a next step, anti-smoking campaigners would like to see this country go the way of Australia, where they’re implementing a brand-free policy that requires all packs to be a standardized olive green (the least attractive colour, according to their research).

“The package is the most prominent form of marketing left in Canada,” says Hammond. “When you put cigarettes in packs called super-slims with a name like Vogue, people are more likely to believe smoking will help them stay slim. So that’s what plain packaging does. You’re undermining the brand value and appeal of the pack, and that’s what the industry dislikes the most.”

Still, Hammond says none of these smoking cessation efforts work in isolation, and, “Hundreds of studies over time have shown that raising price is the most effective tool we have [to curb smoking].” A systematic review of smoke-free policies showed they reduce tobacco use when implemented in worksites and communities.

Julia Belluz is the associate editor at The Medical Post. Seen something that’s Science-ish? Email her at julia.belluz@medicalpost.rogers.com.

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