Evidence growing for pictorial warnings on cigarettes

Over the last 15 years, more than 70 countries around the world have determined that it is important to warn smokers — with large text and dramatic images that often cover much of the cigarette pack — that smoking is damaging to their health. Those pictures draw attention to the warning and illustrate the ill effects of smoking, from lung cancer and heart attacks to strokes and birth defects. Starting in Canada in 2000, the nations that mandated these much more prominent cigarette warnings can be found in such far-flung places as India and Russia, Latin America (Brazil, Venezuela), Europe (Norway, Spain), the Arab world (Qatar, Saudi Arabia), Southeast Asia (Vietnam, Indonesia) and Oceania (Australia, New Zealand).

{mosads}A notable exception is the United States. Formerly a leader in this area of public health, the U.S. has failed to update its cigarette-label warnings since 1984. In that time, the text warnings that sit inconspicuously on the side of pack have become virtually invisible and ineffective. Back in 1965, the United States was the first country to mandate that a health warning be placed on cigarette packs, soon after the surgeon general concluded that smoking was a cause of lung cancer. Then, more than 40 percent of the population smoked and it was acceptable to light up in movie theaters and many other public venues. Today, we have come a long way in reducing the proportion of the population that smokes, but the absolute number of adult U.S. smokers, some 40 million, is about the same as it was in the ’60s. And a new study found that the annual rate of premature death due to smoking is even larger than previously known.

In a bold move, in 2009, the U.S. Congress mandated the use of a more elaborate set of warnings that cover half of the front and back of cigarette packs, and required the Food and Drug Administration (FDA) to develop accompanying color graphics that illustrate the risks of smoking. But three years later, a federal appeals court ruled that the images proposed by the FDA added little value to the mandated text and constituted “unabashed attempts to evoke emotion … and browbeat consumers into quitting.” The court ruled therefore that the proposed labels failed to overcome the free-speech rights of the tobacco companies that brought suit.

Since then, however, there is growing evidence that the images may be a critical part of the message and may help to underscore the importance of the message that has gone lost in the small print on the side of the pack. Recent brain studies using functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) show that these so-called graphic warning labels affect smokers’ brains as well as their behavior in a way that makes them memorable in delivering a public health message.

In an fMRI study recently published online in the journal Tobacco Control, a team at the Annenberg Public Policy Center of the University of Pennsylvania found that those images, when seen repeatedly by smokers, produce a strong emotional response that reduces the immediate urge to smoke. Images with a stronger emotional impact — for instance, a diseased lung, or rotted teeth or a man exhaling cigarette smoke through a tracheotomy hole — were also more likely to be remembered after a delay of only 20 minutes. This is explained in part by other research indicating that emotion-evoking images affect regions of the brain that encode experience. In a prior EEG study of smokers, the same team found that more emotional warning images suppress the brain’s otherwise positive reactions to the sight of cigarettes.

Such promising research shows that powerful pictorial warning labels affect both the brains and the behavior of smokers. Particularly important is the finding that smokers are better able to remember the stronger labels. These results help to demonstrate the educational benefits of graphic warnings.

As this and ongoing research accumulates, the FDA will be in a better position to show the courts that warnings that powerfully illustrate the harms of smoking are more effective than warnings with weak graphics or inconspicuous text. These warnings will add another important mechanism for educating both current and potential smokers that this product is not fit for consumption.

Romer, Ph.D., is associate director of the Annenberg Public Policy Center of the University of Pennsylvania and director of the center’s Adolescent Communication Institute.