It is well established that smokers do not fully understand the breadth or likelihood of smoking-related illnesses1-3 and that graphic health warnings help to increase this understanding.3, 4 New evidence emerges constantly about the health effects of smoking, so there is much yet to be communicated to Australian smokers. Also, countries are contemplating new ways to maximise the effectiveness of the health-related labels and make them even more impactful.
Refreshing graphic health warnings
The Cancer Council Victoria called for the updating of the 2012 graphic health warnings to include statements on new health risks linked to smoking in 2018.5 Australia’s graphic health warnings were approved in 2011. Since then the number of health conditions linked to smoking has increased. The US Surgeon General’s 2014 Report updated the statement of the diseases caused by smoking, bringing the total number of health conditions linked to smoking to 23. The findings of a 2017 study6 conducted by the Cancer Council Victoria suggests that Australians are unaware of the additional health risks now linked to smoking.
The study asked 1,800 Australians whether they thought smoking increased the risk of the 23 health conditions now linked with tobacco use. The majority of participants correctly identified previous known health risks: lung, throat and mouth cancers, heart disease and emphysema. However, half of the smokers surveyed did not know about 13 of the 23 listed health problems. Few participants were aware that smoking was associated with the new health conditions identified in the 2014 report including erectile dysfunction, female infertility, diabetes and liver cancer. These findings reveal the limited awareness of many serious harms of tobacco and present a strong case for refreshing the 2012 warnings.
Targeting individual cigarette sticks
Canada is proposing requirements for health warnings to be placed directly on individual cigarettes. Most of the attention on health labelling has focused on the cigarette pack. However, the cigarette itself is a communication tool. Evidence from a small number of published studies examining consumers perception of dissuasive cigarettes provides evidence that health warnings on individual cigarettes could be used to discourage smoking. A study with young women smokers in New Zealand found that unattractively coloured cigarettes, particularly green or brown coloured cigarettes, were perceived as more harmful than other cigarettes, they or others their age would be less likely to use these cigarettes and that dissuasive sticks led participants to hold negative views of smoking.7, 8 Another study from the UK examined the perceptions of smokers and non-smokers shown an image of a standard cigarette which displayed the warning ‘Smoking kills’. Most participants (71%) thought that the on-cigarette warning would put people off starting to smoke. Approximately half of all participants (53%) thought that an on-cigarette warning would make people want to give up smoking, and the majority (85%) supported a warning on all cigarettes.
Communicating information on toxic constituents on cigarette packs
Adding information on toxic constituents to graphic health warnings increases smokers’ knowledge of toxic constituents and reinforces effects of health warning label messages about the harmful effects of smoking.9, 10, 11 These positive impacts suggest that communicating information on cigarette packages is an effective strategy for discouraging smoking.
Multiple elements impact the influence of constituent messages on smokers but only a small number of studies have examined the best means of presenting these messages on toxic constituents.12, 13, 14 Constituent messages including type of constituent, imagery, and message source to impact their reception among smokers.12 In one study, participants received a message about chemicals in cigarette smoke (e.g., ‘Cigarette smoke has benzene.’) along with an additional randomly assigned messaging strategy: a ‘found-in’ (e.g., ‘This is found in gasoline.’), a health effect (e.g., ‘This causes heart disease.’), both, or neither. Adding a health effect of a toxic chemical elicited greater discouragement from wanting to smoke cigarettes as did adding a found-in. However, including both messaging strategies added little or nothing above including just one. Numeric messaging on toxic constituents have been found to produce the misunderstanding that some cigarettes are less harmful than others.13 However, brief narratives that link toxic constituent messages to tobacco-related health risks promoted cessation when compared to communication that did not explicitly link toxic constituents to disease.13
Findings of a study14 to identify principles for creating effective constituent messages suggest that these messages may have more impact if they pair known constituents with toxic product or health effect information. Smokers rated messages about arsenic, formaldehyde, lead, uranium, and ammonia as more effective than messages about nitrosamines. Messages that contained information on toxic products, health effects, or both received higher effectiveness ratings than constituent-only messages. Among constituent-only messages, those that referenced multiple constituents received higher effectiveness ratings than those with fewer constituents.
More studies are needed to build the evidence base to identify the principles for creating toxic constituents’ messages that effectively discourage smoking12, 15 as well as the mechanisms through which such messages affect change.
Communicating the risk of non-cigarette tobacco products
Consumption of non-cigarette tobacco products (NCTPs) is steadily increasing, particularly amongst young adults and teenagers. Given the increasing use of these products particularly among adolescents and young adults, more research is needed on effective ways to communicate product health harm to those audiences most at risk. In 2017, a systematic review16 of the research on health messages on non-cigarette tobacco products reported that of the 45 studies included in the review, the majority focused on smokeless tobacco (n=32), followed by waterpipe tobacco (n=9), electronic delivery systems (n=2). Only one study focused on reduced exposure products (n=1). Most studies examined knowledge, attitudes, and beliefs as outcomes, while behaviour was an outcome in the minority of studies. Pictorial warnings and public education about these products demonstrated positive impact in some studies.16 None of the studies in the review examined effective communication of health harm of these products.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated March 2021)
1. Weinstein N. Accuracy of smokers' risk perceptions . Annals of Behavioral Medicine 1998;20(2):135–40. Available from: https://academic.oup.com/abm/article-abstract/20/2/135/4630307
2. Weinstein N and Klein W. Resistance of personal risk perceptions to debiasing interventions. Health Psychology, 1995; 14(2):132–40. Available from: https://psycnet.apa.org/record/1995-22738-001
3. Weinstein N, Slovic P, Waters E, and Gibson G. Public understanding of the illnesses caused by smoking. Nicotine & Tobacco Research, 2004; 6(2):349–55. Available from: https://academic.oup.com/ntr/article-abstract/6/2/349/1048072
4. Peters E, Romer D, Slovic P, Jamieson K, Wharfield L, et al. The impact and acceptability of Canadian-style cigarette warning labels among US smokers and nonsmokers. Nicotine & Tobacco Research, 2007; 9(4):473–81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17454702
5. Choahan N. Update graphic images on cigarette packages to remind of health risks, experts say. Royal Australian College of General Practitioners 2018. Available from: https://www.racgp.org.au/newsGP/Clinical/Update-graphic-images-on-cigarette-packages-to-rem
6. Brennan E, Dunstone K, and Wakefield M. Population awareness of tobacco-related harms: Implications for refreshing graphic health warnings in Australia. Medical Journal of Australia, 2018; 209(4):173-4. Available from: https://www.mja.com.au/system/files/issues/209_04/10.5694mja17.01207.pdf
7. Hoek J and Robertson C. How do young adult female smokers interpret dissuasive cigarette sticks?: A qualitative analysis. 2015; 5(1):21-39. Available from: https://www.emeraldinsight.com/doi/abs/10.1108/JSOCM-01-2014-0003
8. Hoek J, Gendall P, Eckert C, and Louviere J. Dissuasive cigarette sticks: The next step in standardised (‘plain’) packaging? 2016; 25(6):699-705. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/25/6/699.full.pdf
9. Cho YJ, Thrasher JF, Swayampakala K, Lipkus I, Hammond D, et al. Does adding information on toxic constituents to cigarette pack warnings increase smokers' perceptions about the health risks of smoking? A longitudinal study in Australia, Canada, Mexico, and the United States. Health Education & Behavior, 2017:1090198117709884. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28715260
10. Brewer NT, Hall MG, and Noar SM. Pictorial cigarette pack warnings increase quitting: A comment on Kok et al. Health Psychology Review, 2018:1-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29478371
11. Brewer NT, Jeong M, Mendel JR, Hall MG, Zhang D, et al. Cigarette pack messages about toxic chemicals: A randomised clinical trial. Tobacco Control, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29654122
12. Kowitt S, Sheeran P, Jarman KL, Ranney LM, Schmidt AM, et al. Cigarette constituent health communications for smokers: Impact of chemical, imagery, and source. Nicotine & Tobacco Research, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29059359
13. Salloum RG, Louviere JJ, Getz KR, Islam F, Anshari D, et al. Evaluation of strategies to communicate harmful and potentially harmful constituent (HPHC) information through cigarette package inserts: A discrete choice experiment. Tobacco Control, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28705893
14. Noar SM, Kelley DE, Boynton MH, Morgan JC, Hall MG, et al. Identifying principles for effective messages about chemicals in cigarette smoke. Preventive Medicine, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28890353
15. Noar SM, Francis DB, Bridges C, Sontag JM, Brewer NT, et al. Effects of strengthening cigarette pack warnings on attention and message processing: A systematic review. Journalism & Mass Communication Quarterly, 2017; 94(2):416-42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29975497
16. Cornacchione Ross J, Noar SM, and Sutfin EL. Systematic review of health communication for non-cigarette Tobacco products. Health Communication, 2017:1-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29236542