Health Warnings on Tobacco Products --- Worldwide, 2007

Many countries require that tobacco product* packaging includes health warnings about the risks associated with tobacco use (1--3). Health warnings on tobacco product packages are effective in highlighting the perception of health risk (4), supporting the intention to quit tobacco use (5), discouraging the intention to begin tobacco use, and increasing cessation rates (6). Prominent displays of health warnings increase their effectiveness; larger warnings, with pictures, are more likely to be noticed, better communicate health risks, provoke greater emotional response, and further motivate tobacco users to quit (7--9). This report assesses the current status of tobacco packaging health warning requirements worldwide. Governments could further discourage tobacco use by requiring prominent health warnings on tobacco packaging.

Placing health warnings on tobacco product packages was one of the key evidence-based interventions included in the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) (2), the first public health treaty negotiated under WHO auspices, which was adopted in 2005. Within 3 years, participating countries agreed to implement health warnings describing the harmful effects of all tobacco products. Article 11 (Packaging and labeling of tobacco products) of WHO-FCTC requires government bodies such as ministries of health to approve and ensure the display of large, clear, visible, and legible warnings on at least 30%, and preferably 50% or more, of the principal display area of tobacco packages.

In early 2007, WHO's Tobacco Free Initiative collected information about legally mandated use of tobacco health warnings through a questionnaire distributed to all 193 WHO member states and one territory. Data specific to health warnings were collected for seven criteria: 1) mandate of specific tobacco use health warnings; 2) inclusion of health warnings on tobacco packs and outside packaging; 3) use of large, clear, and visible health warnings; 4) rotation of health warnings; 5) use of the principal languages of the country; 6) inclusion of pictorial warnings; and 7) descriptions of specific harmful effects of tobacco use in health.

National data collectors were appointed by ministries of health and local WHO offices in each country to complete the questionnaire; regional data collectors, appointed for each of the six WHO regional offices, verified the accuracy and completeness of the data. The regional data collectors in turn submitted the data for further processing and analysis to the Tobacco Free Initiative. The results were validated by each of the member states and then published in 2008 (1).

Data reported from 176 member states indicated that 77 (44%) did not require any warnings on cigarette packs, and 71 (40%) required warnings covering less than 30% of the principal display area. Among the member states, 23 (13%) had warnings that covered at least 30% of the main package display area and included one of the seven warning criteria. Five countries (Australia, Brazil, Canada, Thailand, and Uruguay) (3%) had warnings that covered 50% or more of the principal display areas and included all seven criteria. Among the 176 countries, 15 (9%) required pictorial warnings, and 66 (38%) countries had laws that ban the use of deceptive marketing terms (such as "light" and "mild") that falsely convey that a particular product is less harmful than other tobacco products.

The percentage of member states that had no warnings or warnings that covered less than 30% of the principal package display area was high across all WHO regions: African Region (88%), American Region (74%), Eastern Mediterranean Region (82%), European Region (92%), South East Asia Region (82%), and the Western Pacific Region (71%). The level of implementation of health warnings was associated with a nation's economic status.† Approximately 58% of low-income countries, 45% of middle-income countries, and 24% of high-income countries had not implemented any health warnings (Figure).

Reported by: Tobacco Free Initiative, World Health Organization, Geneva, Switzerland.

Editorial Note:

Guidelines for implementation of Article 11 were adopted in November 2008 to assist countries in meeting their WHO-FCTC obligations. These guidelines propose that national authorities approve regulations that require warnings on display areas of tobacco packaging that are of size and characteristics that will enhance the effectiveness of health warnings (3).

Governments can use cigarette packaging to raise awareness among smokers and nonsmokers about the health risks of tobacco use. Health warnings provide countries with a relatively inexpensive method of informing consumers about the risks of smoking (7). However, findings from WHO's Tobacco Free Initiative indicate that the strategy of placing health warnings on tobacco packaging has been implemented comprehensively in only a few countries.

Countries can require that packaging include larger health warnings, effective text, and pictures. Pictorial warnings combined with text warnings can increase the effectiveness of health messages.§ Pictorial warnings also convey health messages to persons who might not be able to read or understand the written information. To help increase the use of pictorial health warnings, the Tobacco Free Initiative will host a repository of pictorial health warnings and provide training in their use.

Health warnings on tobacco products should not be an isolated tobacco control measure. Instead, countries should implement comprehensive tobacco control programs. To help countries fulfil the requirements of WHO-FCTC, WHO has established MPOWER, a package of technical assistance for six tobacco control policies: 1) monitoring tobacco use and prevention policies; 2) protecting persons from tobacco smoke; 3) offering help to quit tobacco smoking; 4) warning about dangers of tobacco; 5) enforcing bans on tobacco advertising, promotion, and sponsorship; and 6) raising taxes on tobacco. These policies are proven to reduce tobacco use (1,2) and can be effectively supported by legislation requiring prominent health warnings on tobacco packaging.

References

1. World Health Organization. WHO report on the global tobacco epidemic, 2008--the MPOWER package. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf.
2. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2005. Available at http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf.
3. World Health Organization Framework Convention on Tobacco Control. Guidelines for implementation of Article 11 (packaging and labelling of tobacco products) of the WHO Framework Convention on Tobacco Control. Available at http://www.who.int/fctc/guidelines/article_11/en/index.html.
4. Environics Research Group. The health effects of tobacco and health warnings messages on cigarette packages---survey of adults and adult smokers: wave 9 surveys. Toronto, Ontario, Canada: Environics Research Group; 2005. Available at http://www.smoke-free.ca/warnings/warningsresearch/por-04-19%20final%20report%205552%20adult%20wave%209.pdf.
5. Borland R, Hill D. Initial impact of the new Australian tobacco health warnings on knowledge and beliefs. Tob Control 1997;6:317--25.
6. Les Etudes de Marche Createc. Final report: qualitative testing of health warnings messages. Montreal, Quebec, Canada: Les Etudes de Marche Createc; 2006.
7. Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med 2007;32:202--9.
8. O'Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P. Reactions of young adult smokers to warning labels on cigarette packages. Am J Prev Med 2006;30:467--73.
9. Shanahan P, Elliott D. Evaluation of the effectiveness of the graphic health warnings of tobacco product packaging 2008---executive summary. Canberra, Australia: Australian Government Department of Health and Ageing; 2009.

Alternative Text: The figure above shows the percentage of countries that require health warnings on tobacco packaging, by extent of warning required and country income level. The percentage of countries that had no warnings or warnings that covered <30% of the principal display area was high across all World Health Organization regions: African Region (88%), American Region (74%), Eastern Mediterranean Region (82%), European Region (92%), South East Asia Region (82%), and the Western Pacific Region (71%). The figure also shows that the level of implementation of health warnings was related to a nation's economic status. Approximately 58% of low-income countries, 45% of middle-income countries, and 24% of high-income countries had not implemented any health warnings on tobacco packaging.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

Date last reviewed: 5/21/2009