United States: Health warnings on packages change smokers' perceptions

New health warnings are expected to be implemented in the United States in July 2022, the first change in 35 years. A study[1] investigated whether warnings can affect the cognitions and smoking behavior of American smokers.

Health warnings on cigarette packages are recognized as a cost-effective way to raise public awareness of the dangers of tobacco. When combined with other strategies, such as increasing taxes and promoting smoking cessation aids, these warnings enable governments to reduce tobacco consumption and associated health costs. More than 120 countries require health warnings on cigarette packages.[2].

Obsolete warnings, as they have not changed since 1984

Cigarette package warnings first appeared in the United States in 1966 and were last updated in 1984. For the past 35 years, cigarette packages have carried the same warnings emphasizing the link between smoking and lung cancer, emphysema, and cardiovascular disease. Their unchanged content, small size, and lack of images explain their limited effects on smokers' smoking behavior.[3].

New health warnings were mandated by the U.S. Congress in 2009. However, their implementation, initially planned by the Food and Drug Administration (FDA) in 2012, was delayed until 2020 following legal action by the tobacco industry. Finally, in March 2020, the FDA finalized the 11 new " Mandatory warnings for cigarette packaging and advertisements ", with a final effective date of July 13, 2022[4]These new warnings cover the major risks, while opening up to other less well-known, although severe, risks.

Health warnings induce more negative perceptions of smoking

Strong DR et al recruited 357 daily smokers from San Diego who did not want to quit smoking; they were randomly assigned to receive packs of their usual brand of cigarettes in three random designs: either with the graphic warnings currently used on packs in Australia, or packs with no warnings, or finally, standard packs currently available in the USA, with the 1984 warnings.

Participants were followed for three months and interviewed daily about their smoking perceptions and behaviors. Those receiving the packs with the Australian warnings reported significantly more negative perceptions of their smoking than those receiving the current US packs. Health concern among participants in all three groups increased over the course of the study, with a significantly greater increase for participants receiving the packs with the Australian warnings. Finally, these same participants experienced more frequent quitting episodes than those in the other groups, but this difference was not statistically significant.

The authors conclude that their study confirms the value of health warnings, but also the need to support their implementation with other equally effective measures (tax increases, smoking cessation aids, etc.).

An effective measure that saves lives

Article 11 of the WHO FCTC requires the adoption of health warnings on packaging based on numerous studies that have demonstrated the effectiveness of health warnings (text and visual) which effectively inform smokers about the risks they face for their health and can induce a change in their behavior (reducing consumption, stopping it and preventing exposure of relatives to passive smoking) while reducing the attractiveness of the packaging, and therefore of the product. [5]-[6].

Based on the Canadian experience, researchers calculated that if the United States had implemented new graphic warnings in 2012 as originally planned, by 2013 the number of adult smokers would have decreased by between 5.3 and 8.6 million. Based on observations in other countries, another study estimated that new graphic warnings would reduce smoking prevalence by 5% in a few years and that over 50 years, 652,800 deaths would be prevented, as well as 46,600 cases of low birth weight, 73,600 premature births and 1,000 sudden infant deaths.[7]-[8].

Keywords: United States, health warnings, health, smoking

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[1] Strong DR, Pierce JP, Pulvers K, et al. Effect of Graphic Warning Labels on Cigarette Packs on US Smokers' Cognitions and Smoking Behavior After 3 Months: A Randomized Clinical Trial. JAMA Netw Open. 2021;4(8):e2121387. doi:10.1001/jamanetworkopen.2021.21387

[2] Yadira Galindo, Graphic Warning Labels on Cigarette Packaging Changes Perceptions, UC San Diego News Center, August 4, 2021, accessed August 9, 2021

[3] Holly Honderich, Why US lags behind on graphic cigarette warnings, BBC, August 16, 2019, accessed August 9, 2021

[4] Food and Drug Administration, Cigarette Labeling and Health Warning Requirements, Last updated July 9, 2021, accessed August 9, 2021

[5] WHO Eurozone Regional Office, How large pictorial health warnings on the packaging of tobacco products affect knowledge and behavior, 2014

[6] WHO, Showing the Truth, Saving Lives: The Case for Pictorial Health Warnings, Pan American Health Organization, 2009

[7] Huang, J, et al., Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis, Tobacco Control, 23: i7-i12, 2014.

[8] Levy, DT, et al., “Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation,” Tobacco Control, published online November 2, 2016.