Larger Graphic Health Warnings Research Articles

Graphic health warnings and plain packaging in the Philippines: results of online and household surveys.

In line with Article 11 of the WHO Framework Convention on Tobacco Control, the Philippines has implemented graphic health warnings on cigarette packs. To date, there has been no published literature evaluating the perceived effectiveness of GHWs in the Philippines. This study aims to contribute to the evidence on the perceived effects of graphic health warnings (GHWs) in cigarette packaging and the potential impact of plain packaging in the Philippines. The study involved an online convenience survey and a nationwide household survey. Mock-up sets of cigarette packs based on the Philippines' law on GHWs, and Thailand's and Singapore's plain packaging were shown to respondents to rate their attractiveness, quality, taste, cost, social appeal, appeal to youth, noticeability, appeal to non-smokers, attempt to quit, ease of quitting, discouraging smoking, and perceived harm to health on a five-point Lickert scale. The online and household surveys recruited 2,701 respondents in total. Online and household survey respondents considered plain packaging with larger graphic health warnings and visible quitlines from Thailand and Singapore to be more effective in discouraging them from smoking. Both sets of survey respondents also found mock-ups from Thailand and Singapore more motivating for them to attempt quitting than cigarette pack mock-ups from the Philippines. The study concludes that current graphic health warnings in the Philippines are ineffective in instilling health consciousness among Filipinos. Policymakers should consider larger graphic health warnings and plain packaging of cigarettes to motivate smokers to quit and discourage Filipinos from smoking.

Smokers’ perception of cigarette packaging in France before and after the plain packaging

Abstract Background The new mandatory packaging for tobacco products (plain pack with larger graphic health warnings) was implemented in France on January 1st 2017. This study examines the impact of this new packaging on smokers' perceptions of their pack by comparing perceptions before (2016) and after (2017) the implementation. Methods Data come from the Santé publique France Health Barometer, a national telephone survey with random sampling. In the 2016 and 2017 editions, respectively 15,216 and 25,319 adults were asked about their tobacco consumption. Two questions were asked to smokers, identical in 2016 and 2017, on the appreciation of the appearance of the package and on the embarrassment to take out the package because of its appearance. Results - The share of smokers stating they do enjoy the look of their pack was divided by 3 between 2016 (53%) and 2017 (16%). Smokers stating that they are embarrassed of taking out their pack in plain sight because of its look were twice as numerous in 2017 (12%) as in 2016 (6%).A reduce appeal of cigarette pack was observed among the youths (18-25 yo) and they are now as few as their elders to enjoy the look of their pack. Conclusions The introduction of plain packaging has certainly had an impact on smokers' perceptions and, within a strong tobacco control context, probably contributed to denormalize smoking in France. Key messages Since the introduction of plain packaging, appeal of cigarette pack decreased and smokers are more often embarrassed of taking out their pack in plain sight because of its look. Our study suggests that the introduction of plain packaging has had an impact on smokers’ perceptions of their cigarette pack.

Public Health, Intellectual Property, and the Trade and Investment Law Challenges to Australia and Uruguay’s Tobacco Packaging Laws

The trade and investment disputes brought against Australia's tobacco plain packaging laws and Uruguay's large graphic health warnings and restrictions on tobacco brand variants are key cases on the relationship between public health and intellectual property. Both cases have been decided in favour of the respondent states, and they are important victories not only for tobacco control but for public health flexibilities in intellectual property agreements more broadly. Key points to take from the jurisprudence include: its confirmation that trademarks do not give trademark owners the right to use those trademarks to market harmful products, its clarification of the scope of intellectual property protections under international investment law, and its findings on the status of the Doha Declaration on the TRIPS Agreement and Public Health and on interpreting the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights coherently with public health more generally.

'It's like sludge green': young people's perceptions of standardized tobacco packaging in the UK.

Standardized tobacco packaging was introduced in the United Kingdom in May 2016, together with larger graphic warnings. This study explored young Scottish people's awareness of and perceptions about standardized tobacco packaging in the United Kingdom. Qualitative study using 16 focus groups conducted February-March 2017. Four schools in Scotland based in areas of differing socio-economic status (high versus medium/low) and two levels of urbanity (large urban versus small town/other urban). Eighty-two S2 (13-14years) and S4 (15-16years) students who were smokers or at-risk non-smokers. Focus groups explored perceptions of standardized packaging and health warnings. The qualitative data underwent thematic analysis. Views about standardized packaging were generally negative. Packs were described as being unattractive, drab and less appealing than non-standardized versions. The new health warnings generated negative affective, often aversive, responses. These varied depending on the image's perceived 'gruesomeness' and authenticity. Most participants thought that the impact would be greatest on young non/occasional smokers. There were divergent views about whether established smokers would be affected. The introduction of standardized tobacco packaging and new larger graphic health warnings in the United Kingdom seems have reduced the perceived attractiveness of cigarette packs among young people in the United Kingdom who smoke or are at elevated risk of becoming smokers, disrupting positive brand imagery (the brand heuristic), increasing the salience of health warnings and contributing to denormalizing smoking.

Long-term impact of plain packaging of cigarettes with larger graphic health warnings: findings from cross-sectional surveys of Australian adolescents between 2011 and 2017

ObjectiveTo assess the long-term impact of plain packaging (PP) of cigarettes with larger graphic health warnings (HW) introduced in December 2012 on adolescents’ relevant tobacco-related perceptions.MethodsCross-sectional school-based surveys of 12...

Lower smoking rates and increased perceived harm of cigarettes among French adults one year after comprehensive tobacco control measures

ContextFrance has high smoking rates, and recently intensified tobacco control policies spearheaded by the introduction of plain tobacco packaging (PP), and an increase in graphic health warnings (GHW). We examine smoking and e-cigarettes use rates, as well as smoking-related perceptions before (2016) and one year after (2017) comprehensive tobacco control measures. MethodsDePICT is a two waves cross-sectional national telephone survey of French adults aged 18–64 years (2016: 4456 – 2017: 4114). Data were weighted to be representative of the French adult population. Adjusted prevalence ratios (PR, 95% CI) estimating changes between the two study waves were calculated using multivariate Log-Binomial regression models. Main FindingsIn 2017, as compared with 2016, smoking rates (PR = 0.93 (0.88-0.99) and current e-cigarette use (PR = 0.76 (0.61-0.96)) decreased in France. Further, French adults were more likely to report fear of the consequences of smoking (PR = 1.10 (1.06–1.14)) and that smoking is dangerous (PR = 1.08 (1.06–1.11)). Smokers were also more likely to report that health messages on tobacco products are efficient (PR = 1.18 (1.05–1.32)). ConclusionsOur study provides early and encouraging results on potential effects of the comprehensive tobacco control strategies in France introduced in 2017, including PP and larger GHW. Our findings also suggest that e-cigarettes did not replace traditional smoking.

Presenting a strong and united front to tobacco industry interference : a content analysis of Australian newspaper coverage of tobacco plain packaging 2008–2014

ObjectivesIn 2012, Australia was the first country in the world to introduce plain or standardised tobacco packaging, coupled with larger graphic health warnings. This policy was fiercely opposed by industry....

Using public interest litigation for tobacco control: Insights from India.

The Indian notion of "Public Interest Litigation (PIL)" represents a moral and humane process for providing justice to an individual or a group in matters relating to infringement of fundamental rights or denial of civil privileges. The goal of PIL in India is to counter governmental lawlessness, administrative deviance, and exploitation of disadvantaged groups by denying them their rights and entitlements. Although this paper selectively describes the use of the PIL mechanism for ensuring implementation of large graphic health warnings on packages of tobacco products in India, there is a sufficient published literature to corroborate the successful use of this mechanism in India in different tobacco control settings. In fact, over the years, this legal tool has allowed the tobacco control community in India, to extensively promote human rights approach to tobacco control. In the wake of growing interference of tobacco industry worldwide, this paper explores PIL as a potent and effective tool for claiming public health rights related to tobacco control. The PIL has considerable potential to be used for enforcement of tobacco control measures and for stopping tobacco industry from engaging in activities which are detrimental to the health of the people at large. It is important to continuously identify potential avenues through which lessons and recommendations pertaining to PIL could be incorporated into the WHO Framework Convention on Tobacco Control implementation plans and guidelines, with special focus on different intercessional mechanisms that are available from time to time. To set the ball rolling, the authors suggest two such avenues.

Seven years of progress in tobacco control: an evaluation of the effect of nations meeting the highest level MPOWER measures between 2007 and 2014

ObjectiveSince WHO released the package of six MPOWER measures to assist nations with implementing the WHO Framework Convention for Tobacco Control (FCTC), 88 countries adopted at least one highest level...

Does the Judicial Clean Sweep for the New EU Tobacco Directive Mean a New-Fangled Mirth of May?

This working paper examines major developments in May 2016 concerning European tobacco law and policy. Focussing on extensive Court of Justice rulings in three key cases, the legal analysis considers the role of the WHO Framework Convention for Tobacco Control (FCTC) as regards the lawfulness and appropriateness of the new EU Tobacco Products Directive, and more widely EU law and policy for public health given the regulation of other unhealthy lifestyle behaviours. In light of past concerns as to legitimacy and proportionality of EU tobacco control measures and the subsequent emergence of a fundamental rights regime under the EU Charter, this paper considers how convincing the Court has been this time in its interpretation of newly contested measures concerning the European-wide ban of menthol cigarettes, the maiden regime for e-cigarettes, and mandatory standardised product packaging rules including use of large graphic health warnings. The discussion also examines subsequent UK regulations which flow from Article 24(2) of the directive that go beyond EU and FCTC standards as regards packaging measures and the attendant judicial review decision of the English High Court.

Plain packaging implementation: perceptions of risk and prestige of cigarette brands among Aboriginal and Torres Strait Islander people

ObjectivesTo assess the impact of plain packaging with larger graphic health warnings on perceptions of risk and prestige related to different cigarette brands among Aboriginal and Torres Strait Islander people in the Australian Capital Territory. We hypothesised that the changes would decrease perceptions that ‘some cigarette brands are more harmful than others’, and that ‘some brands are more prestigious than others’, and this would be stronger among participants aged ≤35 years, and among smokers compared with non‐smokers. MethodsParticipants completed the survey prior to packaging changes, and were followed up 12 months later (n=98). Repeated measures ANCOVAs assessed perception changes. ResultsFollowing plain packaging implementation, there was a significant reduction in perceptions that ‘some cigarette brands are more harmful than others’. There was no overall change in perceptions of prestige. However, there was a significant interaction for age. Analyses indicated a reduction in perceptions that ‘some cigarette brands are more prestigious than others’ among younger participants (p=0.05), but no change among older participants (p>0.20). There was no interaction for smoking status for perceptions of prestige, indicating smokers' and non‐smokers' perceptions did not differ on this measure. ConclusionsThese findings provide support for the packaging changes.

Does Size Impact Attention and Recall of Graphic Health Warnings?

To evaluate the attention paid to larger sizes of graphic health warnings (GHWs) embedded within cigarette advertisements so as to assess their impacts on rural smokers. Daily smokers (N = 298) were randomly assigned to view a cigarette advertisement with 3 conditions: 2 intervention conditions with GHW comprising 20% or 33% of the ad area, or a text-only control. Eye-tracking software measured attention in milliseconds. Binary outcome mediation was conducted. Intervention participants spent 24% of their time viewing the GHWs, compared to 10% for control (p < .01). The odds of GHW recall in the combined (20% and 33%) intervention group were 3.3 times higher than controls. Total dwell time mediated 33% of the effect of the graphic condition on any recall. GHWs in 20% of cigarette advertisement space attracted significantly more attention than text-only warnings; larger GHWs did not increase attention. Attention was significantly associated with warning recall; total time viewing mediated warning recall. Tobacco ads should include GHWs to attract the attention of smokers.

Tobacco plain packaging: Evidence based policy or public health advocacy?

In December 2012, Australia became the first country to require all tobacco products be sold solely in standardised or 'plain' packaging, bereft of the manufacturers' trademarked branding and colours, although retaining large graphic and text health warnings. Following the publication of Sir Cyril Chantler's review of the evidence on the effects of plain tobacco packaging, the Ministers of the United Kingdom Parliament voted in March 2015 to implement similar legislation. Support for plain packaging derives from the belief that tobacco products sold in plain packs have reduced appeal and so are more likely to deter young people and non-smokers from starting tobacco use, and more likely to motivate smokers to quit and stay quit. This article considers why support for the plain packaging policy has grown among tobacco control researchers, public health advocates and government ministers, and reviews Australian survey data that speak to the possible introductory effect of plain packaging on smoking prevalence within Australia. The article concludes by emphasising the need for more detailed research to be undertaken before judging the capacity of the plain packaging policy to deliver the multitude of positive effects that have been claimed by its most ardent supporters.

Australian adult smokers’ responses to plain packaging with larger graphic health warnings 1 year after implementation: results from a national cross-sectional tracking survey

BackgroundWe assessed whether the Australian plain packs with larger graphic health warnings (GHWs) achieved three specific objectives of reducing the appeal of tobacco, increasing health warning effectiveness and reducing the...

Are quitting-related cognitions and behaviours predicted by proximal responses to plain packaging with larger health warnings? Findings from a national cohort study with Australian adult smokers

BackgroundImplementation of tobacco plain packaging (PP) with larger graphic health warnings (GHWs) in Australia had positive effects on responses reflecting the specific objectives of the PP policy and on follow-up...

Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: findings from a national cohort study with Australian adult smokers

BackgroundPlain packaging (PP) with larger graphic health warnings (GHWs) was implemented in Australia in late 2012. This study examined effects of these packaging changes on short-term changes in quitting-related cognitions...

Do larger graphic health warnings on standardised cigarette packs increase adolescents’ cognitive processing of consumer health information and beliefs about smoking-related harms?

ObjectiveTo examine the impact of plain packaging of cigarettes with enhanced graphic health warnings on Australian adolescents’ cognitive processing of warnings and awareness of different health consequences of smoking.MethodsCross-sectional school-based...

Australian smokers’ support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

BackgroundPlain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the...

The Power of the WHO FCTC: Understanding its Legal Status and Weight

On 27 February 2015, the WHO Framework Convention on Tobacco Control (‘WHO FCTC’) will mark 10 years since its entry into force. In a legal (and political) sense, the WHO FCTC is the international community’s most powerful tool to combat tobacco and the tobacco industry. This chapter argues that, as the treaty’s 10-year anniversary approaches, its legal status, weight and utility often appear to be inadequately understood, and that if this remains the case, its power will not be fully harnessed. It addresses some common misapprehensions, focusing on three points. First, it argues that the WHO FCTC, though originally conceived as a ‘framework convention’ — which would establish a general governance framework, with detailed content and obligations to be elaborated through protocols — became something quite different through the course of its negotiation. While the treaty will always be evolving, it is not waiting for something further to bring it into full being. Second, it offers a guide to the proper interpretation of the WHO FCTC, in which the individual provisions of the treaty are read in the context of the treaty as a whole (including its substantive obligations, guiding principles and preamble), and taking into account its implementation guidelines and other relevant decisions of its Conference of the Parties. Third, it observes that the WHO FCTC’s implementation guidelines are often erroneously viewed against a simple dichotomy of ‘binding’ or ‘non-binding’, whereas in fact the correct question is how they bear on interpretation of the treaty. The chapter then applies this analysis, and guide to interpretation, to the example of large graphic health warnings, arguing that it is incorrect to claim that WHO FCTC parties implementing large graphic health warnings are acting beyond what is required by the treaty.

Effects of dissuasive packaging on young adult smokers

BackgroundTobacco industry documents illustrate how packaging promotes smoking experimentation and reinforces existing smokers' behaviour. Plain packaging reduces the perceived attractiveness of smoking and creates an opportunity to introduce larger pictorial...