Attachment 12.1 Health warnings

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Mandated health warnings on tobacco packaging are a highly cost-effective way to:

• inform consumers about the toxic constituents of tobacco smoke and the health effects of smoking; and
• provide details of where to go for advice on quitting.

Requiring such warnings on every package ensures that smokers and potential smokers see the warnings every time they go to purchase a tobacco product, and every time they handle it. A 20-per-day smoker would be exposed to a health warning around 7000 times each year.

Experience in designing, evaluating and upgrading consumer product information for tobacco products both in Australia and elsewhere indicates that the content, style and presentation of package warnings can greatly affect how noticeable and how memorable they are, and the extent to which consumers understand, believe and feel empowered to act upon the information they contain. Pictorial warnings allow important information about tobacco products to be conveyed to and understood by children and people with limited literacy.

More and more countries are moving to pictorial warnings, with large and extremely potent images required in an increasing number of jurisdictions. It is expected that this trend will continue as parties to the Framework Convention on Tobacco Control move towards implementation of Article 11.

A12.1.1 History of health warnings in Australia

In 1969 legislation was introduced in Australia enabling a health warning to appear on cigarette packages. The legislation was not implemented until 1973, when the simple message 'Warning—Smoking is a health hazard' first appeared.1, 2

A12.1.1.1 Warnings in force between 1987 and 1994

In May 1985, Australian state health ministers agreed that all jurisdictions would introduce legislation or amend regulations to simultaneously introduce four different warnings to appear with equal frequency on all tobacco packages.

The warnings initially agreed upon were: 'Smoking kills', 'Smoking is addictive', 'Smoking causes lung cancer and heart disease', and 'Smoking damages your lungs'. The warnings were to take up 20% of the front and back of the pack, and appear in white type on a black background.

The warnings were bitterly resisted by the tobacco industry, prompting the then Federal Minister for Health, Dr Neal Blewett, to state that:

Ministers have conducted detailed negotiations with the tobacco industry in a sincere effort to reach agreement. Despite our willingness to reach an agreed position, I regret that the industry was unable to make any serious attempt to compromise with Ministers.3

As a direct result of industry pressure the warnings were amended to: 'Smoking causes lung cancer', 'Smoking damages your lungs', 'Smoking causes heart disease' and 'Smoking reduces your fitness'

The attribution statement 'Health Authority Warning' followed each warning. The warnings were printed in 'contrasting colours', selected at the manufacturer's discretion, on the front and back of the pack and occupying 15% of the total face area of the labelled surfaces. The warnings appeared on cigarette and loose tobacco packages, but not on cigar packages. As part of the agreement with the tobacco industry, health ministers undertook not to seek further amendments for a period of five years.3

The warnings also appeared on print advertisements and billboards, by virtue of a mixture of voluntary agreements and legislation, although this did not occur systematically.

A12.1.1.2 Warnings in force between 1995 and 2005

Regulations for improved health warnings were gazetted in March 1994 and (apart from an extension for imported products under transitional provisions in Part 2) took effect for all tobacco products imported or manufactured in Australia after 1 January 1995 (Part 3, Regulation 7).[1] Packets bearing the new warnings began to appear for sale in retail outlets from around March 1995, although small numbers were apparently available before then. Complete phasing out of sales of packages with the old warnings took at least a year.

The new warnings regimen was based on research done by the Centre for Behavioural Research in Cancer commissioned by a Taskforce of officials from the States and the Commonwealth set up by the Ministerial Council on Drug Strategy.

Closely following the recommendations of the CBRC report, in April 1992 the Ministerial Council on Drug Strategy agreed to a number of recommendations for new health warnings and contents labelling on tobacco packaging.5 The recommendations included the following 12 health warnings for rotation: Smoking causes lung cancer; Smoking causes heart disease; Smoking causes emphysema; Smoking is a major cause of stroke; Smoking causes peripheral vascular disease; Smoking reduces your fitness; Smoking kills; Most smokers develop permanent lung damage; Your smoking can harm others; Smoking is addictive; Stopping smoking reduces your risk of serious disease; Smoking in pregnancy can harm the unborn child.

These warnings were to occupy at least 25% of the front of the pack, and appear on the 'flip-top' instead of at the foot of the pack. In addition to the health warning, the whole of the back of the pack was to carry detailed information about the health effects of smoking.

The proposals for strengthened health warnings outlined in the CBRC report to the Ministerial Council on Drug Strategy were strongly supported by the public[2] but were vigorously resisted by the Australian tobacco industry.6 Only the Western Australian government proceeded to gazette regulations to bring these new warnings into effect. Following a change of government, Victorian officials decided not to support the proposed new warnings. At a meeting of the MCDS in July 1993, a compromise set of proposals was once again agreed by all states and territories which saw six of the proposed 12 rotating warnings dropped, and the size of the back of pack information reduced from the full back of the pack to one-third of this panel.7 However, following the meeting, the Victorian Government changed its position a second time, instead announcing that it intended to adopt an entirely different labelling protocol based on that used by the European Community. The EC warnings were more explicit than the current Australian warnings, but not as strong as those agreed upon by the MCDS.8

The then federal Minister for Health, Senator Graham Richardson, responded by announcing that the Australian Government would ensure that labelling of health warnings was uniform across the country, by introducing regulations under federal law which would override those of any state or territory.9 The Trade Practices (Consumer Product Information Standards) (Tobacco) Regulations were gazetted under the Trade Practices Act 1974 on 29 March 1994.

The new regulations required that all cigarette, loose tobacco and cigar packaging (with the exception of cigars sold singly) manufactured from 1 January 1995 had to carry specified health warnings, and that cigarette packaging also had to carry contents labelling. A warning message had to appear on the front of the packaging, with the corresponding explanatory message (providing greater detail) appearing on the back of the pack, and a telephone number for an information service. Each warning and explanatory message was to be followed by the attribution statement 'Government Health Warning'. The following warning messages and explanatory messages were listed in Schedule 1 of the Regulations:

SMOKING CAUSES LUNG CANCER

Tobacco smoke contains many cancer-causing chemicals including tar. When you breathe the smoke in, these chemicals can damage the lungs, and can cause cancer. Lung cancer is the most common cancer caused by smoking. Lung cancer can grow and spread before it is noticed. It can kill rapidly. For more information, call 13 2130.

SMOKING IS ADDICTIVE

Nicotine, a drug in tobacco, makes smokers feel they need to smoke. The more you smoke, the more your body will depend on getting nicotine and you may find yourself hooked. It may be difficult to give up smoking once you are hooked on nicotine. For more information, call 13 2130.

SMOKING KILLS

In Australia, tobacco smoking causes more illness and early death than using any other drug. Tobacco smoking causes more than four times the number of deaths caused by car accidents. For more information, call 13 2130.

SMOKING CAUSES HEART DISEASE

Tobacco smoking is a major cause of heart disease. It can cause blockages in the body's arteries. These blockages can lead to chest pain and heart attacks. Heart attack is the most common cause of death in Australia. Smokers run a far greater risk of having a heart attack than people who don't smoke. For more information, call 13 2130.

SMOKING WHEN PREGNANT HARMS YOUR BABY

Poisons in tobacco smoke reach your baby through the bloodstream. If you smoke when you are pregnant, you greatly increase the chance of having a baby of low birth weight. Smoking may lead to serious complications which could harm your baby. For more information, call 13 2130.

YOUR SMOKING CAN HARM OTHERS

Tobacco smoke causes cancer and poisons people. People who breathe in your tobacco smoke can be seriously harmed. Your smoking can increase their risk of lung cancer and heart disease. Children who breathe your smoke may suffer asthma attacks and chest illnesses. For more information, call 13 2130.

 

Both the warning and the explanatory message had to be printed in black on a white background, within a black border. On a standard cigarette pack, the warning message had to cover at least 25% of the area of the face on which it is printed, and the explanatory message at least 33.3%. Both messages had to be positioned at the top edge of the pack faces, so that the warning message had to appear on the front of the flip-top of packets of cigarettes. The messages had to appear in rotation, so that within the calendar year, each message should appear as nearly as possible on an equal number of retail packages of each brand and variant of tobacco.

The new warning regimen also modified the existing product yield information (based on a voluntary agreement) to one that gave descriptors of the health effects of the components (see main chapter).

The new warnings were found to be effective in improving knowledge and understanding and in eliciting more reactions that are predictive of quitting.10, 11

A12.1.1.3 Pictorial warnings in force since 2006

An evaluation of the 1994 warnings commissioned by the Commonwealth Department of Health and Ageing and conducted in 2000 concluded there was a clear need to enhance both the content and the presentation of consumer information on the retail packaging of tobacco products.12

Consumers agreed that warning labels needed to be upgraded more frequently and should be more tangible and specific to enable smokers to personalise the information presented. Consumers pointed to the need for warnings to be presented in a larger more prominent font, and for warnings to occupy a greater percentage of the pack size. They agreed that Canadian-style graphic warnings taking up more than two thirds of the pack would be a natural progression.12

Developmental research conducted in 200313 confirmed the potential for graphic presentation to greatly enhance the effectiveness of consumer information, and guided the choice of messages and the presentation of materials.

The Technical Advisory group assisting the Commonwealth recommended that the warnings cover 50% of both front and rear pack faces (as well as removing the yield information, which, it was accepted, was misleading). This proposal went to public comment, and was subsequently modified (despite objections by health groups) to cover only 30% of the front and 90% of the back. A major problem with the enacted model is that the 30% at the front is cut by the edge of the flip-top lid, leaving a couple of percent below the lid. This space is effectively rendered useless as there is not enough room for any print and it is separated from the rest once the pack has been opened.

New regulations were passed in 200414 and applied to all tobacco products (cigarettes, loose or pipe tobacco, cigars and bidis) imported into or manufactured in Australia on or after 1 March 2006 (Part 2, Regulation 7(2)). As occurred in 1995, packets bearing the old warnings were still available for sale many months after this date.15, 16

The 2004 regulations require that relevant retail packages[3] display a:

• warning message;
• corresponding explanatory message; and
• if required, the corresponding graphic (Part 4, Division 2, Regulation 35A).

The warning messages, (which have corresponding explanatory messages and usually corresponding graphics) that must be displayed on relevant retail packages are specified in Part 2.2, Division 2.2.1, of Schedule 2. They are:

Group A17 (items 201 to 207 in Schedule 2)
SMOKING CAUSES PERIPHERAL VASCULAR DISEASE
SMOKING CAUSES EMPHYSEMA
SMOKING CAUSES MOUTH AND THROAT CANCER
SMOKING CLOGS YOUR ARTERIES
DON'T LET YOUR CHILDREN BREATHE YOUR SMOKE
SMOKING – A LEADING CAUSE OF DEATH
QUITTING WILL IMPROVE YOUR HEALTH

Group B18 (items 208 to 214 in Schedule 2)
SMOKING HARMS UNBORN BABIES
SMOKING CAUSES BLINDNESS
SMOKING CAUSES LUNG CANCER
SMOKING CAUSES HEART DISEASE
SMOKING DOUBLES YOUR RISK OF STROKE
SMOKING IS ADDICTIVE
TOBACCO SMOKE IS TOXIC

Manufacturers or importers much ensure that, during the periods outlined below, each warning appears roughly on an equal number of packages of each different kind of cigarette, loose or pipe tobacco[4] (Part 4 Division 2, Regulation 36(1)), with:

• 
  
• messages in group B appearing in the eight months from 1 March in every odd year (Part 4, Division 2, Regulations 36(2)(b)); and
• warnings from either set appearing from 1 November to the end of February any year (Part 4, Division 2, Regulation 37).[5]

The regulations specify (Part 3, Division 1 Regulation 11) that the Regulations 26 and 27 specify the formatting requirements of warning messages, explanatory messages and information messages on retail packages[6]  Part 4, Division 1, Regulation 26 states: manufactured or imported on or after 1 March 2006.

(1) A warning message on the front face of a retail package, and an explanatory message on the back face of a retail package, must be in the following format:

(a) the text must be printed on a black background;

(b) the text must be printed in the type face known as Helvetica, in upper-case and lower-case letters as the text of the message is set out in Part 2.2 of Schedule 2, in type that is:

(i) clear and legible; and

(ii) subject to paragraph (c), of the same point size throughout the message; and

(iii) white; and

(iv) of normal and bold weight as the text of the message is set out in Part 2.2 of Schedule 2; and

(v) of such a size that the text as nearly as possible fills the background on which it is printed; and

(c) for a warning message, the words ‘Health Authority Warning’ must be in type of a point size not greater than 50% of the point size of the type used for the  remainder of the message.

(2) A warning message on the back face of a retail package must be in the following format:

(a) the text must be printed on a red background;

(b) the text must be printed in the type face known as Helvetica, in upper-case and lower-case letters as the text of the message is set out in Part 2.2 of Schedule 2, in type that is:

(i) clear and legible; and

(ii) subject to paragraph (c), of the same point size throughout the message; and

(iii) white; and

(iv) of normal weight; and

(v) of such a size that the text as nearly as possible fills the background on which it is printed; and

(c)  the words ‘Health Authority Warning’ must be in type of a point size not greater than 50% of the point size of the type used for the remainder of the message.

For a retail package, the information message must (Part 4, Divison1, Regulation 27):

(a) be clear and legible; and

(b) be in the type face known as Helvetica, and in bold type; and

(c) be printed in white text on a black background; and

(d) be in upper and lower case, as shown in Part 2.5 of Schedule 2; and

(e) be of such a size that the text fills, as nearly as possible, the background on which it is printed.

The Regulations specify the size, position and placement of the warning message, corresponding explanatory message and corresponding graphic for each type of relevant retail package (See Part 2.1 Division 2.1.1 of Schedule 2 in relation to cigarettes and Division 2.1.2 in relation to loose or pipe tobacco). [7] Part 2.3 of Schedule 2 provides diagrams showing required layouts.

Regulation 29 states that if a message or graphic is likely to be obscured by a wrapper on the package, the message or graphic must also appear on the wrapper. It must also not be likely to be obliterated, removed or rendered permanently unreadable when the retail package is opened in the usual way.

Similar provisions apply for retail packages of cigars. Labelling requirements are contained in Division 2.1.3 of Schedule 2, warning messages, explanatory messages and graphics are detailed in Division 2.2.3 of Schedule 2 and examples of layouts in Part 2.4 of Schedule 2. Each warning message, corresponding explanatory message and corresponding graphic must be rotated on retail packages of cigars so that each message appears, as nearly as is practicable, equally on each brand of cigar over a 24 month period beginning on or after 1 March 2006 (Part 4, Division 4, Regulation 44).

Bidis and nasal snuff do not currently require graphic warnings (see Parts 2.7 and 2.8 of Schedule 2 for relevant formats and warnings).

A12.1.2 Health warnings used in other countries

A health warning has been required to appear on the packaging of tobacco products in the United States since 1966.

By 1991, 77 countries required warnings, with the majority of countries requiring warnings by 1999.19 However, warnings vary greatly from country to country in both size and potency.

Canada introduced pictorial health warnings in December 2000, closely followed by Brazil in 2002. Belgium (2006), Brazil (improved in 2004 and again in 2008), Chile (2006), India (2007), Jordan (2006), Malaysia (from March 2009), New Zealand (2008), Singapore (2004, and again in 2006), Thailand (2005, and again in 2007), Uruguay (2006), Venezuela (2005) and the UK[8] have now all finalised laws requiring picture-based warnings.

Countries in the 27-member European Union (EU) have the option of requiring picture-based warnings, choosing from among 42 picture messages prepared by the European Commission.

The governments of the Czech Republic, Hong Kong, Iran, Ireland, Latvia, Mexico, Portugal, Romania and South Africa have all stated that picture-based warnings are now under consideration.20

A12.1.3 Evidence about the effects of health warnings

Most of the early scientific research[9] about the effectiveness of tobacco health warnings comes from studies of the first three waves of Australian warnings.6, 10, 11, 21-24 More recently there have been evaluations of Canada's world first graphic warnings in late 200023, 25 implementation of European Union warnings in the UK in 2003, of Australia's latest 2006 graphic warnings26–28 and Thailand's new (2005) graphic warnings.

In May 2009 the International Tobacco Control Policy Evaluation Project released a comprehensive assessment of the impact of health warnings internationally.29 The ITC Project is an ongoing international study that now covers 19 countries around the world.30 This report evaluates health warnings on tobacco products (including text and graphic warnings). 

There is no doubt that warnings have an impact on smokers.

They are frequently noticed and read (or looked at) and they sometimes invoke thought about the harms of smoking and thoughts about quitting; and they occasionally lead to smokers forgoing cigarettes they would otherwise have smoked. Some smokers also take steps to avoid stronger warnings, this being more so for graphic than text warnings.26, 27, 31 In all cases studied, new warnings (strengthened either with increased size and or use of graphics) have been more effective in stimulating targeted reactions than those they replaced. Some of this effect is due to novelty, but it is clear that objectively stronger messages persistently evoke greater levels of responses than weaker ones.

Reactions to warnings, especially those that induce deeper cognitive processing or immediate behavioural responses are independently predictive of the smoker making subsequent quit attempts.10, 27 Avoidance of warnings is also predictive of making attempts.27, 29

Introduction of stronger health warnings has been shown to have increased knowledge of the subject matter contained in the warnings both in Canada29, 32 and in Australia in 1987,22 in 199511, 200633 and in 2009.28, 29

Smokers have greater knowledge about particular health effects in countries where those health effects are the subject of warnings than in countries where they are not.23, 29

Health warnings stimulate reactions that are predictable antecedents of quitting attempts.27 Stronger warnings stimulate more of these reactions, including thinking about the harms, thinking about quitting and foregoing cigarettes as a result of the warnings, and the relationship between these reactions and quitting appears to be independent of warning strength, suggesting they are consistent predictors of quitting.

In the Netherlands, placement of the national Quitline number on packs with text-based warnings led to a marked increase in numbers of calls,34 and calls to the Quitline in Australia also increased after introduction of improved consumer product information in 2006, which included a requirement to list the Quitline number.35

A study conducted over 2005 and 2006 indicated that Australian warnings were noticed by the majority of adolescents and increased cognitive processing about the health risks covered. Intention to smoke was lower among those students who had talked about the warning labels and foregone cigarettes.36

Opposition to improved health warnings by tobacco companies suggests that tobacco industry executives believe that such measures would affect sales.2

A12.1.4 What makes an effective health warning?

Research on the effects of health warnings can be divided into research on the content of the warnings and research on the form. There is more direct research on form, while much of knowledge we have about the effects of content is either from analogue studies done when considering which warnings to implement, or from other areas of communication research, not specifically related to warnings about tobacco on packs in the marketplace.

A12.1.4.1 Knowledge about effects of content of warnings

A review of theories and evidence, largely from social psychology37 suggests that warnings are more likely to be effective if they:

• Not only promote negative attitudes to smoking, but also promote positive attitudes to quitting
• Combine strong fear appeals with information about how risk can be avoided
• Convey a sense of the negative social as well as negative health consequences
• Focus on the relevant attitudes of the target groups
• Increase perceived self-efficacy
• Promote discussion about smoking among smokers friends and family
• Confront self-exempting beliefs.

Health warnings can be effective in attracting and maintaining attention, processing information and encouraging action so long as messages are clear, noticeable, strong, direct and frequently rotated.37

A12.1.4.2 Knowledge about the effects of varying forms of warnings

Numerous studies have been conducted in Canada,38 Australia4, 12, 13 and elsewhere to guide the design of health warnings. This is a growing field of research, and knowledge is building quickly as to optimal design of warnings. See the University of Waterloo's Tobacco Labelling Resource Centre for up-to-date information.[10]

Wording matters

Obscure text warnings have little impact. Messages that depict health risks in a vivid and emotionally arousing manner are most effective.39

Analysis of warnings on cigarette packaging in the United States indicates that comprehending them requires college-level education40, greatly reducing usefulness with young people, less educated people, and people with poorer reading skills. Comprehension and impact of warnings is greatly increased if they are expressed in clear simple language.41

Size matters

Size can refer to the amount of space given over to the warning, the size of the font of the message or the size of any picture. It is likely that all elements of size are important.

Smokers are more likely to recall larger warnings, with bigger warnings associated with greater appreciation and acceptance of risk.4, 29, 32, 42, 43

Post-implementation research confirms beyond doubt that increased warning size (at least up to 50% of the front surface, the largest warnings so far studied), increases warning effectiveness.

Research recently undertaken for the Canadian Government found that health warnings occupying 75% of the pack were more effective than warnings occupying 50% of the pack in conveying information about the health risks of smoking.44 Based on the analysis of 38 different indicators, researchers concluded, however, that warnings needed to increase to 90% in order to 'connect with emotions of various styles of young smokers' and 'make cigarette packs less attractive'.

Font size should be as large as possible, and warnings should take up as much of the pack as possible.28, 44, 45 Consumers prefer warnings to appear in a boxed section.46

Placement matters

Smokers show better recall for warnings that appear on the front, compared to the side of packages.4, 42, 46, 47

Research on the new Australian warnings, which average more than 50% of the two main sides, indicates them having weaker effects than the Canadian warnings with have 50% of both sides dedicated to warnings, suggesting that the back of the pack is less effective than the front, presumably because material on the front is noticed more often.26 Borland and Lal found that over 90% of packs displayed in public venues (mainly café tables) were front up.48 Smokers tend to have the front of the pack facing them rather than the back each time they remove a cigarette for smoking. Experimental work has also shown that the top of the front is likely to have greater impact than the bottom of the front.4

A Philip Morris document also highlights the importance of positioning on the front of packages:

'Government required warnings placed on the largest packaging panel, often called the front and/or back, are the biggest marketing threat to all of us in Asia...'49.

Pictures probably work best

Warnings may be particularly important in communicating health information to people with impaired literacy.50 There is some evidence that graphic warnings may lead to more frequent and deeper processing of warning information than text-only warnings although there have been no head-to-head comparisons of warnings of the same size and theme but differing in presentation (graphic vs text only).26, 27

Following introduction of pictorial health warnings in Canada, more than 90% of smokers reported noticing the change. Forty-four percent of smokers said the new warnings increased their motivation to quit. In several studies in Canada,51 more than one-third of former smokers indicated that warning labels had influenced their decision to quit, with approximately three times as many endorsing the policy (in combination with smoke-free areas) as a motivator to quit than was the case prior to the introduction of graphic health warnings.52, 53

Very vivid graphic health warnings have not been followed by adverse outcomes that some commentators feared—namely that people would "switch off" and avoid looking at and attending to the warnings. Greater fear and disgust is associated with greater likelihood of quitting.54 Avoidance of health warnings is not associated with reduced quitting; indeed there is evidence that it may actually be associated with increased quitting, although not necessarily independent of other reactions to the warnings.10, 26

Context matters

It is now well established that the warnings need to be on a pre-specified background (e.g. white for black text), because otherwise companies can effectively blend the warning into the design of the pack.11 Smokers recall warnings more effectively on mock packets with a plain backgrounds than they do on real, highly stylised cigarette packets.55–58 This strongly suggests that plain packaging would increase the effectiveness of health warnings. Plain packaging is discussed at length in Chapter 11, Section 11.6.3.

Wear-out is only partial

Australian research shows that the peak levels of response to warnings is in the period immediately after their introduction onto packs,11 perhaps even before all packs on the market have them on.59 There is some decline in cognitive responses as consumers become used to seeing the images on the packs; warnings appear to lose some, but not all of their impact with time.23, 26, 35

A12.1.5 What has been the impact of the 2006 warnings in Australia?

In 2009, a report by Patrick Shanahan and David Elliott prepared on behalf of the Australian Government Department of Health and Ageing was released ("Report").28  The intention of the Report was to evaluate the effectiveness of health warnings (both graphic and accompanying explanatory messages) in increasing knowledge of the health effects of smoking, encouraging cessation of smoking and discouraging smoking uptake or relapse.

Methodology

The research conducted in preparing the Report included:

• a literature review of graphic health warnings both in Australia and overseas;
• qualitative and quantitative research of the effectiveness of graphic health warnings and explanatory messages on tobacco product packaging including:

• group discussions (with 24 qualitative target audience groups divided into eight groups of committed smokers, 6 groups of recent quitters,[11] five groups of contemplators[12] and five groups of non-smokers);
• a national telephone survey (of 1304 individuals); and
• stakeholder interviews (28 key informants from organisations involved in tobacco control).

For further information on the methodology used in preparation of the Report, see Section 3: Methodology p 33–37.

Report Findings

Awareness of health warnings

Two out of three people involved in the telephone survey were aware of changes to tobacco and cigarette packaging made in the last two years.  Awareness was particularly high among smokers (86 percent) and recent quitters (80 percent).

There was a decrease in the number of smokers who were aware of health messages and information on the front (from 98 percent in 2000 to 91 percent in 2008) and side (from 67 percent in 2000 to 46 percent in 2008) of the cigarette pack.  However, there was an increase in the awareness of warnings and information on the back of the pack (from 62 percent in 2000 to 73 percent in 2008). A similar pattern was observed with non-smoker groups. 

Readership

Readership of health information (text) among smokers and recent quitters was as follows in Table 1:

The above table shows that, whilst readership of the front of the pack was greatest, there was a decrease in readership of both the front and side of cigarette packs but an increase in readership of the back.  The report notes that this appears to have been influenced by the inclusion of graphic warnings which are more prominent on the back of packs.

For further information on awareness of health warnings, see Section 5.2: Noticeability of Graphic Health Warnings, p 60 to 76.

Importance, believability and effectiveness of health warnings

The Report demonstrates that there is strong public support for the inclusion of health warnings on packs of tobacco and cigarettes. Seventy-one percent of individuals who participated in the telephone survey indicted that it was ‘very important' that health warnings be contained on tobacco and cigarettes with a further 14 percent stating that it was ‘quite important'.

A significant majority of smokers and recent quitters found the health warnings to be believable, particularly those that referred to well known smoking related health issues and those that had appeared in anti-smoking television campaigns.

The Report concludes that the use of graphic images has effectively increased the impact of public health messages about the health consequences associated with smoking. Those who participated in the telephone interview claimed that the use of graphic images, as opposed to text only warnings:

• had resulted in improved knowledge of consequences;[13]
• would help to prevent people from taking up smoking;[14]
• was more effective in helping ex-smokers to stay quit;[15] and
• helped to deglamourise smoking.

Awareness of the Quitline has improved since 2000 with 63 percent stating that they were aware that the Quitline telephone number was included on tobacco packs. Five percent of interviewees said they had called the Quitline.

The Report concludes that there have been significant positive movements in attitudes relating to smoking since the introduction of graphic health warnings including an increase in:

• knowledge of health risks associated with smoking;
• concern about the risks of smoking; and
• the intention to quit.

For further information on importance, believability and effectiveness of health warnings, see Sections 5.3 to 5.8.

Wear out

The report acknowledges that there is some evidence that health warnings can become less effective once they become familiar.

Plain packaging

A majority of people (57%) agreed with a statement that cigarettes should be sold in plain packs to assist smokers to quit.  Smokers acknowledged that the design and colour of cigarette packaging is an attraction to purchase or try a brand.  It was also mentioned that pack design negatively impacts on recall of health warnings. 

Stakeholder response to graphic health warnings

Stakeholders provided a positive response to the use of graphic health warnings on tobacco packs.  Overall, stakeholders perceived that the existing range of graphic health warnings was well balanced and effective but that there were further improvements that could be made including:

• refreshing pack design elements of graphic warnings to improve impact;
• developing and maintaining an integrated strategy in relation to graphic health warnings; and
• implementing plain packaging.

For further information on stakeholders' responses, see Section 6: Stakeholder Reactions to Graphic Health Warnings, p165.

Recommendations

The Report suggests a number of improvements that were raised by consumers, stakeholders and in other research studies covered in the 2008 Literature Review. These include:

• Use clear, well-defined images to reduce confusion in identifying and understanding graphic images;
• Increase the size of graphic warnings on the front of the pack to improve readership (which has declined since 2000);
• Improve readership of the side of pack by simplifying the text and including content such as tips to quit, larger Quitline number and/or simplified ingredients information;
• Refresh the existing health warnings, introduce new warnings and add new images to existing text warnings to reduce overexposure and ensure the impact of the message is sustained;
• Ensure that text messages are simple and clear by using non-technical language and choosing appropriate font style and size; and
• Further use of statistics in text warnings to increase the sense of urgency, use pronouns to personalise the messages and introduce messages that relate to social consequences.
• Align graphic images used on cigarette packs with other media forms such as television campaigns;
• Use graphic health warnings on other tobacco products such as cigars sold individually and on water pipes; and
• Introduce plain packaging to remove conflict and competition between the pack design and health warnings.

For further information on the suggestions raised in the Report, see Section 7.5: Areas for Improvement and Future Consideration, p186. [28]

A12.1.6 World Health Organization recommendations on health warnings

Article 11 of the Framework Convention on Tobacco Control (FCTC) states

Each Party shall, within a period of three years after entry into force of this Convention for that Party, adopt and implement, in accordance with its national law, effective measures to ensure that:

... Each unit packet and package to tobacco products and any outside packaging and labelling of such products also carry health warnings describing the harmful effects of tobacco use, and may include other appropriate messages. These warnings and messages: i Shall be approved by the competent national authority; ii shall be rotating; iii shall be large, clear, visible and legible; iv should be 50% or more of the principle display areas but shall be no less than 30% of the principle display areas; v may be in the form of pictures or pictograms.

Australia was the lead key facilitating country for the drafting of guidelines to assist parties in meeting their obligations under Article 11 of the FCTC. The draft guidelines for Article 11 were made available on 31st August 200860 and were adopted by Parties to the Framework Convention on Tobacco Control at the third session of the Conference of the Parties to be held in South Africa in November 2008.61

A12.1.7 Public support for health warnings

Large pictorial warnings are credible and have high levels of public support.28

Warnings have proved popular both in Canada54 and in Thailand.62

A majority of American residents would support the introduction of Canadian style graphic health warnings on tobacco products in the US.63 In Brazil, three months after the introduction of pictorial health warnings in 2002, 73% of smokers approved of them, and 67% said the warnings made them want to quit. The impact was especially strong in those with low incomes and education.64 Two years after large pictorial warnings were introduced in Uruguay, 62% of adult smokers stated that they would like to see more information about health effects on the packet.65 Data from the International Tobacco Control Policy Evaluation study in 2007 showed that 62% of Australian smokers thought the amount of information was about right, 25% would like more, leaving only 13% who thought it excessive (Borland 2008, personal communication).

Acknowledgement

Thank you to Caroline Miller from the Cancer Council of South Australia for advice and unpublished data on the impact of the 2005 Australian graphic health warnings. Thank you to Dr Ron Borland for data from the International Tobacco Control Policy Evaluation Study and for extensive comments and to Sharyn Walsh and Janet de Ruyter from the Department of Health and Ageing for noting several items needing correction incorporated in updated version, April 2009.