Smoking is a serious global health problem (and the leading cause of preventable death), currently causing nearly six million deaths every year from direct consumption or indirect exposure, of which one million occur in the Americas ¹1. World Health Organization. WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: World Health Organization; 2013.. Given this reality and the addictive nature of tobacco, public policies are needed to reduce (or eliminate) tobacco consumption, especially cigarettes ²2. Campaign for Tobacco Free Kids, 2017. https://global.tobaccofreekids.org (acessado em 13/Abr/2017).
https://global.tobaccofreekids.org... ^,33. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003.. The World Health Organization (WHO) thus launched negotiations in the 1990s for the first multilateral treaty to protect the human right to health, through the Framework Convention on Tobacco Control (FCTC) ³3. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003., in force since February 27, 2005. A milestone in human rights that places the right to health above trade agreements and copyright treaties, the FCTC recommended a series of measures to reduce the demand for tobacco, especially by controlling consumption (i.e., education, addiction treatment), marketing (i.e., prices, taxes, content, packaging, advertising), and measures against exposure to tobacco smoke in society. Importantly, the FCTC also includes provisions on reduction of the tobacco supply, environmental protection, accountability issues, scientific and technical cooperation, and communication of information.

The changes recommended by the FCTC include a ban on tobacco sales (especially cigarettes) in packaging that displays the company colors and logos associated with brands ³3. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003.. These would be replaced by new packaging with standard dimensions in which the background would be a single color, with warning labels and images on the health risks from tobacco. The only carry-over from the old display would be the brand name, but always printed in the same font, color, and size, since cigarette and other tobacco product packages influence individual perception and are thus capable of “tricking” the products’ consumers ³3. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003..

When the tobacco industry perceived the threat to one of its promotional tools, it launched a series of maneuvers against the adoption of plain packaging, arguing that the effectiveness of such changes had not been proven scientifically and that the change would have no real effect on tobacco consumption ⁴4. Freeman B, Chapman S, Rimmer M. The case for the plain packaging of tobacco products. Addiction 2008; 103:580-90.. In reaction to these maneuvers, a series of studies were conducted with smokers and non-smokers to investigate the psychological (i.e., perception), social (i.e., social appeal), and biological effect (i.e., neurological activation) of cigarette pack images on smoking prevalence and prevention. The aim of the current article is to present the results of these studies − and thus the scientific argument behind this specific provision in the FCTC that has motivated bills of law in Brazil and elsewhere in the world.

Studies have generally shown that when compared to non-smokers, smokers consider cigarettes less harmful to health ⁵5. Hammond D, White C, Anderson W, Arnott D, Dockrell M. The perceptions of UK youth of branded and standardized, 'plain' cigarette packaging. Eur J Public Health 2014; 24:537-43.. Tobacco products in plain packs are generally perceived as having higher levels of toxicity and health risk when compared to brand packs ⁶6. Bansal-Travers M, Hammond D, Smith P, Cummings KM. The impact of cigarette pack design, descriptors, and warning labels on risk perception in the US. Am J Prev Med 2011; 40:674-82.^,77. Germain D, Wakefield MA, Durkin SJ. Adolescents' perceptions of cigarette brand image: does plain packaging make a difference? J Adolesc Health 2010; 46:385-92., thus reducing the demand for tobacco ⁸8. Thrasher JF, Rousu MC, Hammond D, Navarro A, Corrigan JR. Estimating the impact of pictorial health warnings and "plain" cigarette packaging: evidence from experimental auctions among adult smokers in the United States. Health Policy 2011; 102:41-8.. Neuroimaging studies show that brand packs activate brain areas related to reward processing (i.e., ventral striatum, inferior frontal gyrus, and ventromedial prefrontal cortex) ⁹9. McClure SM, Li J, Tomlin D, Cypert KS, Montague LM, Montague PR. Neural correlates of behavioral preference for culturally familiar drinks. Neuron 2004; 44:379-87.^,1010. Schaefer M. Neuroeconomics: in search of the neural representation of brands. Prog Brain Res 2009; 178:241-52..

Other studies suggest that warnings on the hazards of tobacco are perceived more readily when presented on plain packaging ¹¹11. Beede P, Lawson R. The effect of plain packages on the perception of cigarette health warnings. Public Health 1992; 106:315-22.^,1212. Goldberg ME, Liefeld J, Madill J, Vredenburg H. The effect of plain packaging on response to health warnings. Am J Public Health 1999; 89:1434-5.. A meta-analysis comparing graphic and text messages concluded that graphic warnings are more effective than text-only warnings in reducing tobacco consumption ¹³13. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 2015; 25:341-54.. The inclusion of graphic warnings produces greater activation of areas of the brain responsible for cognitive and emotional decisions (i.e., medial prefrontal cortex and amygdala) ¹⁴14. Green AE, Mays D, Falk EB, Vallone D, Gallagher N, Richardson A, et al. Young adult smokers' neural response to graphic cigarette warning labels. Addict Behav Rep 2016; 3:28-32.^,1515. Wang AL, Romer D, Elman I, Turetsky BI, Gur RC, Langleben DD. Emotional graphic cigarette warning labels reduce the electrophysiological brain response to smoking cues. Addict Biol 2015; 20:368-76., as well as areas involved in processing self-regulation (i.e., medial prefrontal cortex), associated with motivation to eliminate consumption ¹⁴14. Green AE, Mays D, Falk EB, Vallone D, Gallagher N, Richardson A, et al. Young adult smokers' neural response to graphic cigarette warning labels. Addict Behav Rep 2016; 3:28-32.^,1616. Falk EB, O'Donnell MB, Tompson S, Gonzalez R, Dal Cin S, Strecher V, et al. Functional brain imaging predicts public health campaign success. Soc Cogn Affect Neurosci 2016; 11:204-14.. Concerning the packaging color and format, packs with a white background (both plain and conventional brand packs) and with a more attractive format (e.g., lipstick for women) suggest less risk to health when compared to plain brown packs or branded packs with different-colored backgrounds ¹⁷17. Hammond D, Dockrell M, Arnott D, Lee A, McNeill A. Cigarette pack design and perceptions of risk among UK adults and youth. Eur J Public Health 2009; 19:631-7.^,1818. Hammond D, Doxey J, Daniel S, Bansal-Travers M. Impact of female-oriented cigarette packaging in the United States. Nicotine Tob Res 2011; 13:579-88..

From the social point of view, studies show that plain packaging reduces the appeal and attractiveness of tobacco consumption and produces a negative perception of the cigarette’s flavor (compared to cigarettes in brand packs) ¹⁹19. Hammond D, Daniel S, White CM. The effect of cigarette branding and plain packaging on female youth in the United Kingdom. J Adolesc Health 2013; 52:151-7.^,2020. Hoek J, Gendall P, Gifford H, Pirikahu G, McCool J, Pene G, et al. Tobacco branding, plain packaging, pictorial warnings, and symbolic consumption. Qual Health Res 2012; 22:630-9.^,2121. Scheffels J, Lund I. The impact of cigarette branding and plain packaging on perceptions of product appeal and risk among young adults in Norway: a between-subjects experimental survey. BMJ Open 2013; 3:e003732.^,2222. White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health 2012; 12:737.. The perception towards individuals that smoke also changes: smokers of tobacco products with plain packs are seen as addicts, outdated, and belonging to a lower social class than smokers of brand packs ⁷7. Germain D, Wakefield MA, Durkin SJ. Adolescents' perceptions of cigarette brand image: does plain packaging make a difference? J Adolesc Health 2010; 46:385-92.^,2323. Lund I, Scheffels J. Young smokers and non-smokers perceptions of typical users of plain vs branded cigarette packs: a between-subjects experimental survey. BMC Public Health 2013; 13:1005.^,2424. McCool J, Webb L, Cameron LD, Hoek J. Graphic warning labels on plain cigarette packs: will they make a difference to adolescents? Soc Sci Med 2012; 74:1269-73..

In light of such extensive evidence ²⁵25. World Health Organization. Plain packaging of tobacco products: evidence, design and implementation. Geneva: World Health Organization; 2016., numerous countries have begun to adopt public policies to change tobacco product packaging. In just over 15 years, 105 countries have enacted public policies to control tobacco consumption through graphic warnings on cigarette packs and other tobacco products. Brazil was the second country in the world to suggest the use of graphic health warnings on cigarette packs, in 2002, even before the country ratified the FCTC ²⁶26. Presidência da República. Decreto nº 5.658, de 2 de janeiro de 2006. Promulga a Convenção-Quadro sobre Controle do Uso do Tabaco, adotada pelos países membros da Organização Mundial da Saúde em 21 de maio de 2003 e assinada pelo Brasil em 16 de junho de 2003. Diário Oficial da União 2006; 3 jan.. Since then, different guidelines have been established to control smoking, such as restrictions that included a ban on cigarette advertising on TV and other in mass media such as magazines, newspapers, billboards, and radio. However, the country has still not adopted a public policy to enforce plain packaging on tobacco products, as suggested by Articles 11 and 13 of the FCTC ³3. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003.. Meanwhile, the combination of brand packs and graphic health warnings sends an inconsistent health message to consumers ²⁴24. McCool J, Webb L, Cameron LD, Hoek J. Graphic warning labels on plain cigarette packs: will they make a difference to adolescents? Soc Sci Med 2012; 74:1269-73.. The WHO recommendation of completely standardized, plain packaging appears to be ideal for promoting healthy habit changes in the population ²⁵25. World Health Organization. Plain packaging of tobacco products: evidence, design and implementation. Geneva: World Health Organization; 2016..

Australia was the first country to adopt completely standardized plain packaging through the Tobacco Plain Packaging Act 2011, in force since 2012. The United Kingdom and France began the implementation process in 2016, and Hungary has similar plans for 2018. At least 14 other countries, including Canada, Norway, South Africa, Uruguay, New Zealand, and Thailand, are developing a formal process or are formally considering plain packaging ²⁷27. Canadian Cancer Society. Cigarette package health warnings - international status report. s.l.: Canadian Cancer Society; 2016..

The Brazilian National Congress is currently reviewing three bills of law on plain packaging. The first bill, PLS 103/2014 (https://www25.senado.leg.br/web/atividade/materias/-/materia/116679), proposes plain packaging with no advertising features, only the brand name in black lettering on a white background, and with health warnings on smoking. PL 1,744/2015 (http://www.camara.gov.br/proposicoesWeb/fichadetramitacao?idProposicao=1301095) is similar to the previous bill, but leaves the definition of the standardized color on the inner and outer surfaces of the packs and the brand name’s color, size, and font to a regulation to be issued by the National Health Regulatory Agency (Anvisa). Finally, PLS 769/2015 (https://www25.senado.leg.br/web/atividade/materias/-/materia/124339?o=d), also proposes the implementation of plain packaging based on standards regulated by Anvisa, while adding a ban on flavor additives in cigarettes, defining smoking in automobiles as a traffic violation when there are passengers under 18 years of age, and banning advertisement of cigarettes and other tobacco products.

Such bills are consistent with the results of international studies and research in Brazil showing that the use of completely standardized plain packaging reduces the social appeal of tobacco consumption in adolescents and young adults when compared to partially standardized plain packaging (the dimensions of which are standardized, with a single-color background, but containing additional descriptors on content, e.g., flavor) and the use of packs with the brands displayed ²²22. White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health 2012; 12:737.. However, passage of these bills is uncertain, since there are members of Congress that lobby for the tobacco industry’s interests and employ various strategies to block such legislation, as noted by Valeska Figueiredo, coordinator of the Center for Studies on Tobacco and Health at the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (Cetab/Ensp/Fiocruz) ²⁸28. Vargas T. Dia Mundial Sem Tabaco: padronização das embalagens é o foco. https://portal.fiocruz.br/pt-br/content/dia-mundial-sem-tabaco-padronizacao-das-embalagens-e-o-foco (acessado em 06/Dez/2016).
https://portal.fiocruz.br/pt-br/content/... . The stance against plain packaging makes no sense, given the need to safeguard the human right to health and in light of the scientific consensus. Many tobacco-related diseases can be prevented or reduced by government action based on WHO recommendations for the adoption of plain packaging. The studies reviewed here show promising evidence of effectiveness in the reduction of tobacco consumption through plain packaging with graphic and text warnings on health hazards.

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