If Americans think the proposed graphic warnings for cigarette packs are frightening, they should see what's on packages in other countries.
The U.S. Food and Drug Administration (FDA) last month proposed 36 possible illustrations and will pick one to run with each of nine new health warning statements it is to require on packaging and ads as of October 2012. Up until now, U.S. cigarette packs have carried only text warnings, and those haven't changed since 1985.
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The USA is playing catch-up with countries on every continent, and some researchers say a number of its proposed images aren't scary enough.
At least 39 countries or jurisdictions have picture warning requirements, and many more are in the process of implementing them, according to a new report by the Canadian Cancer Society.
While Canada in 2001 was the first to add picture warnings, many other countries have surpassed it, the cancer society says. One problem, critics say, is that after spending much time and money developing new ones, the Canadian government has never changed them. As a result, the warnings' effectiveness has waned.
Uruguay, on the other hand, is battling tobacco giant Philip Morris International , teh producer of Marlboro cigarettes , over its warnings, which cover 80% of the package, the largest in the world. The company has filed an arbitration claim with the World Bank alleging that Uruguay's warnings violate its trade agreement with Switzerland, where Philip Morris is based. The warnings leave little space "for display of legally protected trademarks," the company said Oct. 5. In addition, Philip Morris alleges, "repulsive and shocking pictures, such as a grotesquely disfigured baby," don't accurately depict health effects.
Many countries besides Uruguay require images that are bigger and harsher than those proposed by the FDA, which include women blowing smoke in children's faces and diseased lungs.
Some of the proposed pictures are cartoons, not photographs, and using them would be "really risky," because smokers might not take them seriously, says Jeremy Kees, an assistant professor of marketing at Pennsylvania's Villanova University.
"Believability is one of the key issues for warnings," Kees says.
The FDA might have been concerned that "gross-type" visuals would offend smokers, evoking anger instead of a desire to quit, he says. But his research has found that the scarier the images, the more likely smokers were to say they felt inspired to quit.
"It doesn't matter what the theme is," he says. "The more fear-evoking, the more graphic, the more positive the response by smokers."
Brazil's anti-smoking images, introduced in 2002, have been called the scariest in the world. The third set, added last year, include a gangrenous foot and what appears to be a fetus in an ashtray. They must cover the entire front or back of a pack. (In the USA, the proposed images are supposed to cover at least the top half of the front and the back.)
And Brazil's warnings are working, says Eliane Volchan, an associate professor of neurobiology at the Federal University of Rio de Janeiro. Smoking rates in Brazil fell by more than half from 1989 to 2006, Volchan says, from 34.8% to 16%. The U.S. rate has been stuck at around 20% for the past five years.
Volchan's views on the FDA's images are mixed. Some should be effective in scaring smokers smokeless, but others might not. "Highly aversive warning images should be selected," she says. "Those portraying harms of smoking ... are better."
Her research has found that pictures of people smoking on cigarette packs might have opposite the desired effect. "Smoking-related images and words are craving triggers for smokers and should be avoided," Volchan says.
Several images proposed by the FDA fall into that category. One simply shows a woman smoking in the rain. One photo and one cartoon show women blowing smoke in their children's faces. A couple of images show smokers annoying non-smokers, while one image is simply a lighted cigarette.
Tobacco companies have filed a lawsuit challenging the legality of requiring larger and more graphic warnings on U.S. cigarette packs. They say such a move would end up burying their logos at the bottom of the packages.
Australia is planning to go a step further. As of July 2012, there won't be any logos on cigarette packs sold in the country, says Mike Daube. Manufacturers won't even be allowed to use colors or fancy type fonts to distinguish their packages.
Daube, a health policy professor at Curtin University in Perth, was deputy chairman of the task force that recommended plain packs in Australia. Their only adornment will be text and pictures depicting smoking health risks.
"It essentially means that the government takes over the full design of the pack," he says. "The industry has no say whatever."
Brazil has also discussed plain wrappers, Volchan says. Andrew Lansley, the secretary of state for health in Great Britain, which introduced graphic images in 2008, issued a statement last month saying his government is considering such a move.
"The evidence is clear that packaging helps to recruit smokers," so it makes sense to make it less attractive, he says.
The 2009 Tobacco Control Act doesn't give the FDA authority to go that far. Still, Daube says, it is of "special importance" that the U.S. is finally adding pictures, because many countries, especially in the developing world where smoking continues to increase, look to it as an example.
Says Daube: "If warnings like these are implemented in the U.S., where much of the tobacco industry is at home, and where it is at its most powerful, this will send out a striking signal that Big Tobacco is losing its influence."
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