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Packing a Heavier Warning
Elsewhere, Cigarette Boxes Bear Graphic Evidence of Smoking's Ill Effects; U.S. Labels Will Soon Do the Same

By Ranit Mishori
Special to The Washington Post
Tuesday, August 4, 2009

Coming soon to the lives of American smokers: cigarette labels that go far beyond a simple warning.

Imagine gruesome color photographs showing a mouth riddled with cancer, lungs blackened, a foot rotten with gangrene. If the images sound sickening, well, that's the point.

Under a law signed by President Obama on June 22 -- the Family Smoking Prevention and Tobacco Control Act -- tobacco companies will be required to cover 50 percent of the front and rear panels of cigarette packages with color graphics showing what happens when you smoke and bold, specific labels saying such things as:

"WARNING: Cigarettes cause fatal lung disease."

"WARNING: Tobacco smoke can harm your children."

"WARNING: Smoking can kill you."

The first U.S.-mandated label in 1965 tentatively suggested "Cigarette Smoking May Be Hazardous to Your Health." Although the language changed over time, critics have long dismissed U.S. labeling as anemic and ineffective.

Indeed, the inspiration for the new labeling standards comes from abroad. Canada started the trend in 2000 with a label that showed a picture of mouth cancer. "It's the one that smokers remember more than anything else. Even after nine years," says David Hammond, a researcher from the Department of Health Studies at the University of Waterloo in Ontario. Since then, he says, more than two dozen countries have picked up on the idea.

A sampling of how explicit the labels can be: Malaysia's cigarette packs bear a photo of a diseased lung; some in Brazil show a dead fetus lying near cigarette butts; Thailand's show a person with a hole in his throat, to warn about throat cancer; in New Zealand, it's a gangrenous foot.

Compare these with the American warning label, which has not changed since 1985: no images, and only a small-type surgeon general's warning that states: "smoking by pregnant women may result in fetal injury, premature birth and low birth weight."

"Every piece of research that I've seen with smokers tells us that smokers think that [pictorial warnings] are more effective," Hammond says. "U.S. smokers and consumers are getting worse health information than almost any other smoker in the world."

While it is true that smoking rates in the United States are lower than in other countries -- about 20 to 22 percent of the adult American population smokes -- experts have long argued that a more powerful message would have a far greater impact on smoking habits.

One out of five American adults is still too many smokers, says Mitch Zeller, a former director of the Food and Drug Administration's Office of Tobacco Programs. "That's an unacceptable figure. Just because our smoking rate may be lower than other countries around the world is not an argument against graphic warnings when we still have so many people smoking in this country."

According to the Centers for Disease Control and Prevention, more than 440,000 U.S. deaths are attributed to cigarette smoking every year. That includes deaths from heart disease, lung cancer, obstructive lung disease, other cancers, stroke and other conditions. An estimated 49,000 of these deaths are the result of secondhand-smoke exposure.

"The health effects of smoking are inherently hard and frightening," Hammond says. "Lung cancer is not a pretty disease. Mouth cancer is not pretty. And any warning that falls short of communicating that probably isn't doing its job."

The bigger the warnings are and the more vivid they are, he says, the more they will make people pay attention, "particularly warnings that elicit negative emotions, like fear or disgust."

The World Health Organization agrees. In May, the organization called for all countries to adopt picture-based warnings on all tobacco packages, calling them "among the strongest defences against the global epidemic of tobacco." But not everybody agrees that fear and disgust are appropriate buttons to be pushing.

"We are not enthusiastic about any type of graphic image openly displayed in our stores," says Lyle Beckwith of the Association of Convenience and Petroleum Retailing, a trade group that represents more than 2,000 retailers and their suppliers.

Philip Morris, the country's largest manufacturer of tobacco products, supported the legislation, which, in addition to requiring stronger warnings, allows regulators to control the amount of addictive nicotine in a cigarette and bans most cigarette flavorings. The rest of the industry opposed the legislation.

Hammond does not think cigarette makers will mount legal battles, because lawsuits in other countries have failed. He said there were such challenges with the earliest graphic labels in Canada, "but the industry lost. . . . They challenged the E.U., they lost. They lost everywhere, and I would doubt that they would challenge it" in American courts.

Longtime smoker Karyn Kimberling, president of the smokers' rights group Virginia Smokers Alliance, sees the coming labels as an attempt to "de-normalize and demonize" smokers and doubts habits would change. "Grotesque labels have not changed people's habits in other countries," she says, "so I don't know why it would here."

There is, however, research to support claims that graphic warnings educate smokers on the dangers of their habit, and even motivate some to quit. American smokers shown a set of graphic Canadian warning labels, for example, rated them "substantially more of a deterrent than text-only labels" in a CDC-sponsored study published in the American Journal of Preventive Medicine.

Similarly, an international telephone poll tested several thousand people on their awareness that smoking is linked to heart disease, stroke and lung cancer, among other illnesses. The calls were made in four countries: the United States, Canada, Australia and the United Kingdom. Researchers found higher level of awareness in Canada and Australia, and credit that to the more explicit labels in those countries. Impotence, for example, is specifically mentioned on Canadians labels, and Canadians polled were twice as likely to agree that smoking can cause impotence as were people from the other three countries.

Hammond keeps pressing the argument that "pictures are more likely to catch people's attention and to hold people's attention over time," especially if the message reaches kids.

"Even the most hardened, recalcitrant smoker will often tell us, 'Well, they don't have an effect on me, but my 6-year-old keeps coming up to me and saying, "Daddy, this is going to happen to you?" ' " Hammond says. "That does not happen with the text warning."

Additionally, says Hammond, text warnings don't work well with those who can't read -- mostly minority populations who don't have a high level of literacy in English. "For those millions of people, you might as well be writing a health warning in Mandarin if it only has text," he says. "You put a picture on it and it broadens the scope of those things to millions more people who cannot read English, many of whom are from a lower socioeconomic status and are more likely to smoke anyway."

The legislation says that the Department of Health and Human Services "shall issue" regulations governing the upgraded labels within two years.

Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine. Comments: health@washpost.com.

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