EDITORIALS
Gruesome photos on cigarette packages reduce tobacco use
Rob Cunningham*
Canadian Cancer Society, 116 Albert Street, Ottawa, ON, Canada
The WHO Framework Convention on Tobacco Control (FCTC)1 - the international tobacco treaty - is revolutionizing health warnings on tobacco product packaging worldwide. The treaty was approved on 21 May 2003, came into force on 27 February 2005 and now has 165 Parties.
Article 11 of the FCTC provides that package health warnings must be at least 30% - and should be at least 50% - of the package's front and back (on average). The use of pictures is optional. The FCTC obligations apply to all types of tobacco products, to both cartons and individual packages, whether they are imported or made domestically in a Party's jurisdiction. Parties have 3 years to implement these obligations under Article 11.
When FCTC negotiations began in 2000, only three countries (Canada, Poland and Thailand) met the eventual 30% minimum size standard, and only Canada had adopted regulations to meet the recommended standard of 50% coverage with pictures.
The tobacco product package is the most cost-effective communication medium available to governments to convey health messages. Well-designed warnings are very effective.2-4 Warning messages are determined by health departments and paid for by tobacco companies.
Package warnings reach the entire population. They provide mass public education and work 24 hours per day, 7 days per week. A consumer may take out a package 20 times per day, i.e. about 7300 times per year. Packages are seen by others, including by spouses, children, friends and co-workers. Packages can thus have an impact on both consumers and non-consumers.
As the FCTC Guidelines recognize, health warnings with graphic images of the negative health effects are far more effective than text-only warnings.5 A picture does indeed say a thousand words. Compared to text-only warnings, pictures are more noticeable, more memorable and have more emotional impact. Indeed, WHO chose pictorial warnings as the 2009 theme for World No Tobacco Day.6
Picture-based warnings are especially important in developing countries where there are higher rates of illiteracy and low literacy. How useful is a text-only warning to a person who cannot read? And some people might not be able to read the official language(s), such as some immigrants, temporary workers and individuals from minority language groups.
The number of countries adopting picture-based health warnings for cigarette packages is rising rapidly, with at least 28 jurisdictions with finalized requirements and many more countries in the process. Progress is excellent. Several web sites reproduce actual warnings.7-10
The tobacco industry itself uses pictures in its advertising and on packages. If the industry uses pictures to promote tobacco use, how can the industry credibly object when health departments want to use pictures to discourage tobacco use? But the industry continues to actively lobby against larger picture-based warnings in many countries. Obviously, it knows that picture warnings will have an adverse impact on overall sales. In India, the bidi industry (which produces flavoured tobacco hand-rolled in leaves) has opposed such warnings precisely because the warnings would reduce sales.
It is recommended that a rotated series of package warnings include a broad range of messages because there are many health effects of tobacco use and because different messages resonate with different people. Cessation advice can also be effective. Governments are increasingly obtaining copyright permission to use warning images developed by other governments.
The effectiveness of health warnings increases with their size, as the FCTC Guidelines recognize. Bigger warnings make them more visible, more important and have greater impact. They also allow for more text, a larger font size and bigger/better pictures. A growing number of countries require warnings even larger than the 50% FCTC standard.11,12 The FCTC Guidelines urge Parties to "aim to cover as much of the principal display areas as possible".5
Warnings should be located on both the package's front and back. If warnings are only required to appear on one side, the industry will choose to place the warnings on the back. If a warning is only on one side, it is much less visible. A consumer can leave the package without the warning showing on kitchen tables, restaurant tables and desks. In retail displays, based on international experience, the side without the warning will normally be the one displayed to consumers. While warnings should appear on both the front and back, the front is more important than the back because it is more visible. In addition, warnings should appear at the top (not the bottom) of the front and back to increase visibility.
Internationally, further innovations can be anticipated. For example, health warnings, perhaps including a pictogram, should be included directly on the cigarette itself, as well as on equipment used in water pipe smoking. A rotated series of warning messages might include non-health messages, e.g. "Quit, save money". Warning size could be increased from 90% to 100% of the package front and back.
Plain packaging should be implemented, thus requiring the brand portion of all packages to be the same base colour (e.g. brown), prohibiting logos or design elements and stipulating that the brand name appear in a standard font, font size, colour and location on the package, and standardizing package format. Plain packaging would make health warnings more visible, would end the industry's promotional use of the package and would curb the industry's deceptive packaging techniques.
Package warnings are a key tobacco control measure. By implementing effective package warnings, governments can prevent addiction, reduce disease and save lives. 
References
Available at: http://www.who.int/bulletin/volumes/87/8/09-069559/en/index.html
References
1. WHO Framework Convention on Tobacco Control [Internet site]. Available from: http://www.who.int/fctc/text_download/en/index.html [accessed on 7 July 2009] .
2. Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ 2009;87:640-643.
3. Hammond D. Tobacco labelling & packaging toolkit: a guide to FCTC article 11. Waterloo, ON: Tobacco Labelling Resource Centre; 2009. Available from: http://www.tobaccolabels.ca/tobaccolab/iuatldtook [accessed on 7 July 2009] .
4. Canadian Cancer Society. Controlling the tobacco epidemic: selected evidence in support of banning all tobacco advertising and promotion, and requiring large, picture-based health warnings on tobacco packages. Ottawa, ON: Canadian Cancer Society & International Union Against Cancer; 2001.
5. Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and labelling of tobacco products). In: Third session of the Conference of the Parties of the WHO Framework Convention on Tobacco Control, Durban, South Africa, 17-22 November 2008. Available from: http://www.who.int/fctc/guidelines/article_11/en/index.html [accessed on 7 July 2009]
6. World No Tobacco Day, 31 May 2009 [Internet site]. Geneva: World Health Organization;2009. Available from: http://www.who.int/tobacco/wntd/2009/en/index.html [accessed on 7 July 2009] .
7. Tobacco Labelling Resource Centre [Internet site]. Available from: www.tobaccolabels.org [accessed on 7 July 2009] .
8. Picture warnings [Internet site]. Ottawa, ON: Physicians for a Smoke-free Canada;2009. Available from: http://www.smoke-free.ca/warnings [accessed on 7 July 2009]
9. Campaign for effective health warnings on cigarette packs [Internet site]. Available from: www.graphicwarnings.org [accessed on 7 July 2009] .
10. Warning labels: overview. Washington, DC: Campaign for tobacco-free kids; 2009. Available from: http://www.tobaccofreecenter.org/resources/warning_labels [accessed on 7 July 2009]
11. Cigarette package health warnings: international status report. Otttawa, ON: Canadian Cancer Society;2008. Available from: http://www.tobaccofreecenter.org/files/pdfs/en/WL_status_report_en.pdf [accessed on 7 July 2009] .
12. Cunningham R. Cigarette package warning size and use of pictures: international summary. Ottawa: Canadian Cancer Society; 7 July 2009. Available from: http://www.tobaccolabels.ca/labelima/healthwarn [accessed on 13 July 2009] .
* Correspondence to Rob Cunningham (e-mail: rcunning@ottawa.cancer.ca).