GRAPHIC warnings printed on cigarette packs about the dangerous effects of smoking have encouraged more smokers to reduce smoking or quit the habit altogether than text-only warnings, a new study by researchers at the University of North Carolina has found.
The study, entitled “The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies,” was carried out by a team of researchers from the University of North Carolina Lineberger Comprehensive Cancer Center. The team was led by Dr. Seth Noar, who is also a professor at the UNC School of Media and Journalism. The National Cancer Institute and FDA Center for Tobacco Products funded the study, and it was published in this month’s edition of the journal Social Science & Medicine.
The study gathered and assessed the results of 32 earlier research studies conducted in 20 countries. Twenty of the studies specifically analyzed the impact of replacing text warnings on the cigarette pack with graphic warnings that include text and pictures, while the remaining studies looked at efforts to strengthen existing text or picture warnings in other ways, such as changing their size, content, or position on the pack.
The Philippines was not among the 20 countries studied in the earlier research, despite an aggressive campaign by the government through the Department of Health to enforce the use of graphic warnings on cigarette packs.
“Our review focused on studies that analyzed smoking behavior and other outcomes conducted in the real world where countries had implemented new warning policies,” Noar said. He explained that in his team’s study, the US was used as a control, as text-only warnings on cigarettes persist in spite of a 2011 rule by the US Food and Drug Administration requiring graphic warnings. However, the FDA rule was blocked by the US Court of Appeals in response to a legal challenge by tobacco companies. The case is not yet resolved.
In the study’s introduction, the researchers highlighted that their work was the first study to pool data from thousands of participants across multiple studies and estimate the size of population-wide effects of strengthening cigarette pack warnings. This allowed them to draw general conclusions from the research results.
Among the specific findings, the study found that strengthening warnings led to a 10 percent relative increase in knowledge about the health effects of smoking among smokers, which increased to 32 percent when countries added new warning content. Graphic warnings or otherwise strengthened warnings also resulted in a 9 percent relative increase in quit attempts, and a 13 percent relative reduction in smoking prevalence.
The research also found that calls to “quit smoking” telephone help lines increased in four out of six studies, overall cigarette consumption measured on national scales decreased in three of eight studies, and reported attempts to quit increased in four out of seven studies.
The researchers noted that when the studies that addressed health warning efforts other than graphic warnings were excluded, the results of their overall analysis was identical, leading them to conclude that graphic warnings are indeed effective in encouraging smokers to quit.
The researchers were careful to note that because the study gathered real-world results, other factors could have contributed to the declines in smoking behavior observed in the review. For example, Noar explained, countries that strengthened their warnings sometimes made other changes, such as implementing media campaigns, raising taxes on cigarettes or implementing advertising restrictions.
Nevertheless, he highlighted an independent commentary on his team’s research, a review by professor Joseph Cappella of the University of Pennsylvania and published along with the research study, which stated, “Putting this review in the context of other recent controlled studies about cigarette warnings, we see an emerging picture of the causal effectiveness of warning labels emerges that is difficult to ignore.”
In a follow-up statement Noar said, “One of the responsibilities of governments is to educate the populace about the many negative health effects of smoking. Our review clearly demonstrates that stronger warnings—particularly graphic warnings—achieve this in a more effective way than text-only warnings. When combining this review with other research evidence that’s continuing to emerge, we see that warnings clearly have a real-world impact on knowledge, attitudes, and, importantly, perhaps on behavior itself.”