This authoritatively counters industry misinformation that better warnings have no incremental impact. The FCTC Guidelines, which represent an international consensus, recognise that ‘well-designed health warnings and messages on tobacco product packages have been shown to be a cost-effective means to increase public awareness of the health effects of tobacco use and to be effective in reducing tobacco consumption’. 2 The FCTC Guidelines also recognise that warnings ‘that contain both pictures and text are far more effective than those that are text-only’ and ‘have the added benefit of potentially reaching people with low levels of literacy and those who cannot read the language(s)’ of text-only warnings. 2įCTC Guidelines for implementation of Article 11 on packaging and labelling (FCTC Guidelines), adopted in 2008, recognise ‘that the effectiveness of health warnings and messages increases with their size’ and that Parties should ‘aim to cover as much of the principal display areas as possible’. The FCTC itself recognises the fundamental importance of health warnings, with the FCTC’s very first guiding principle stating in part, ‘Every person should be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke’. The FCTC, with 182 Parties as of September 2021, includes in Article 11 mandatory minimum requirements for Parties: warnings must be at least 30%-and should be 50% or more-of the principal display areas, which for cigarettes is the package front and back pictures may be used there must be rotated messages, rather than a single unchanging message messages can include non-health messages warnings must be in the language(s) of the country the requirements apply to all categories of tobacco products. 50 When the FCTC was approved in May 2003, Brazil was the only other country to require picture warnings or to have at least a 50% size on average (Brazil had 0% front, 100% back). When negotiations for the FCTC began in October 2000, only Canada had required warnings with graphic pictures, and had required a size of at least 50% of the package front/back. 47 48 Although a large proportion of these countries still had a single weak warning, more and more were strengthening requirements. 45 46īy 1996, there were at least 127 countries/jurisdictions with legislated or voluntary warnings. 43 44 In 1994, Canada required eight rotated black and white text warnings in about the top 35% of the package front/back. 42 In 1993, Thailand required 10 rotated text warnings covering 25% of the package front and back. 7 In 1977, Sweden required 16 rotated messages, with information on specific health effects, to appear in about 20% of the front or back using black on white or other dark on light colour 40 41 this lasted until 1993 when Sweden implemented European Union (EU) 4% text warnings. In 1973, Australia required a warning on the front of the package, but with small text that could be in package colours. 3 Warnings were initially located on the lateral side of cigarette packages, with a single warning using weak general language, with no mention of cancer, heart attacks or other specific health effects. Package health warnings first appeared in the 1960s and 1970s on a legislated or voluntary basis, beginning with the USA in 1966. This paper aims to provide a historical overview of package warning developments, particularly over the last 30 years to outline the role of the FCTC to identify tobacco industry strategies and arguments that have been overcome to identify other labelling issues and to outline why tobacco package health warnings have seen such global success. Indeed, if better warnings did not work, then why has the tobacco industry been so strongly opposed? Health concerns are a key reason for quitting or considering quitting, 37–39 and warnings provide health information. 8 10 21–36 In a sense, research has proved the obvious. The evidence in support of the effectiveness of well-designed warnings, including the incremental effectiveness of larger warnings, and picture-based warnings instead of text-only warnings, was supported with evidence in Canada 16–20 and has long been overwhelming and has increased over time. Packaging has promotional value, 11–15 and larger graphic warnings reduce the package’s promotional impact and denormalise the product. 2 9 10 This is especially the case given that most tobacco consumers begin as adolescents younger than the legal age, when they have even less awareness. Well-designed warnings decrease tobacco use and increase awareness of the health effects, 2 and are an effective government response to the underawareness and underappreciation of the vast range of health consequences and their magnitude.
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