The extent to which health warning labels on tobacco packages impact risk perceptions and smoking behavior largely depends upon the size, prominence, position, and design of these messages. Warning labels that cover up to at least 50% or more of principal display areas, and not just limited to the sides of the tobacco package, are associated with increases in health knowledge and motivation to quit. Experimental studies in Canada demonstrate that increasing the warning label from 50% to 75%, 90%, or 100% increased its effectiveness among youth. Studies evaluating graphic, pictorial warning labels in Canada and Australia have shown high levels of cognitive processing and an association between cognitive processing, intentions to quit, and quit attempts. In Brazil and Thailand, countries with strong pictorial depictions on the health impacts of smoking, had the strongest impact on thinking about quitting among current smokers. Nationally representative data from Canada demonstrate that 80% of youth reported pictorial health warning messages decreased the attractiveness of smoking. Compared to small, text-only warning labels, large warning labels that include images in addition to text are more effective at communicating health risks associated with use, cannabis dry rack evoking an emotional response, provoking thoughts about quitting, increasing motivations and quit attempts among smokers.
National data from Canada show that 95% of youth rated pictorial health warnings as more effective at communicating health risks than text-only versions. Large pictorial warnings have longer lasting effects on increasing risk perceptions, encouraging quitting and quit attempts among smokers, and are more likely to be seen by low-literacy adults and children. In contrast, small, text-only warning labels, such as those used for tobacco in the United States, have low impact on youth tobacco use. In addition, these warning labels do not effectively communicate health messages on the specific health risks of tobacco consumption to the public. Young people are less likely to recall seeing text-only warning labels. Among participants that report text-only warning label recall, only one-third were able to accurately recall message content. Additional requirements for effective warning labels include positioning health messages on front and back, and on the top of all principal display areas. Warning labels on tobacco packages are more effective when novel health warnings and messages are used, and the content, layout, and design of the warning label are rotated periodically to avoid “burn out” of stale messages. While youth perceive health messages on US warning labels for tobacco products to be believable, 186 few reported that these messages were informative or relevant, and that these messages were “vague”, “stale”, and “worn-out”.
Warning labels that include messaging with cessation information and a toll-free quitline number are associated with an increase in calls to the quitline, particularly among male smokers and those from low socioeconomic groups, and help to address tobacco-related health disparities.Implementation of comprehensive warning labels for tobacco packaging has been actively opposed by tobacco industry interference in the policy process. Between 1984 and 2003, countries without mandated HWL on tobacco packages transitioned to having either some form of HWL or a voluntary industry HWL passed by the tobacco companies. Countries with voluntary industry HWLs were less likely to adopt comprehensive HWLs, which were compliant with FCTC guidelines than countries with previously enacted mandated HWLs. These findings also point to the importance of implementing at the time of legalization a comprehensive set of demand reduction policies for marijuana before a large marijuana industry develops and works to weaken or defeat public health strategies to control use.Cigarette pack design is a key component to tobacco company marketing techniques. Package design establishes brand identity and promotes brand appeal, particularly among youth. Tobacco companies design products that are attractive to children while being marketed toward young adult peers. A longitudinal study on youth attitudes toward cigarette brands found a ten-point increase in the proportion of teenage girls reporting a favorite cigarette brand between 2007 and 2008.
The study coincided with the launch of RJ Reynold’s campaign for Camel No. 9, a brand that appears to be specifically designed to attract teenage girls, and which accounted for the majority of the increase in brand preference. Similar impacts on brand preference were found among young people in Mexico that had reported a greater exposure to tobacco marketing and advertising. Tobacco companies use package design techniques to mislead consumers into perceiving their products as less harmful or safer than other tobacco products. Tobacco product packaging with descriptors such as “natural”, “light”, “mild”, and “organic” are associated with false beliefs of the health risks of smoking, and are perceived as less harmful or healthier than tobacco products without these descriptors, likely because the tobacco companies target concerned195 and older smokers at risk of quitting. Indeed, the cigarette companies consider the color of the package as an “ingredient” of the cigarettes that can be used to manipulate users’ perception of the taste of the product in ways interchangeable with changes in the physical product itself. The effectiveness of health warnings may be enhanced through the use of standardized packaging , a strategy used to reduce attractiveness and appeal of tobacco, to increase the prominence of health warnings, and to correct misperceptions on the health risks of smoking. Plain packaging enhances the effectiveness of health warnings by increasing their notice ability, and has been shown to make smoking less appealing and has the potential to reduce the level of false beliefs about the risks of different brands. Compared to branded packages, tobacco products in standardized packaging are associated with reduced brand awareness and identification, and reduced brand appeal, particularly among young women. Consistent with previous research in high-income countries, plain packaging in low and middle-income countries have similar impacts on reducing tobacco product appeal. Consistent with adopting a comprehensive tobacco control approach, plain packaging may be useful even if nations have adequately funded mass media campaigns . Unlike media campaigns, packaging changes have almost universal reach and ongoing frequency of exposure. Packaging changes cost little to governments, unlike media campaigns that constantly have to justify their funding allocations against ongoing efforts by tobacco companies to defund media campaigns. As discussed in detail in the next section, plain packs with larger graphic health warning labels complement media campaign messages, amplifying their impact. There is broad scientific consensus that mass media campaigns aimed at the general population are an important element of a comprehensive program to prevent youth initiation of tobacco use and reduce its prevalence. The 2012 US Surgeon General Report concludes that there is sufficient evidence to infer a causal relationship between the level of funding for anti-smoking media campaigns and reduced smoking prevalence among youth. The effectiveness of well-done anti-tobacco media campaigns is not an argument against other elements of a comprehensive tobacco control policy. Indeed, media campaigns can amplify the effects of other policies, such as plain packaging, advertising restrictions, graphic warning labels and smoke free laws, as well as the other way around, since marketing prohibitions reduce the salience of pro-smoking cues, and increase and reinforce anti-smoking norms.
In particular, in Australia, introduction of pictorial health warnings on cigarette packets was supported by a televised media campaign highlighting illnesses featured in two of the warning labels .206 Between 2005 and 2006, trimming tray the proportion of smokers aware that gangrene is caused by smoking increased by 11.2 percentage points , and awareness of the link between smoking and mouth cancer increased by 6.6 percentage points . In contrast, awareness of throat cancer decreased by 4.3 percentage points, and this illness was mentioned in the pack warnings but not the advertisements. Smokers who had prior exposure to the warnings were significantly more likely to report positive responses to the advertisements and stronger post-exposure quitting intentions. Thus, anti-smoking television advertisements and pictorial health warnings on cigarette packets reinforced each other to positively influence awareness of the health consequences of smoking and motivation to quit. Analysis of the impact of tobacco control policies and mass media campaigns on smoking prevalence in Australian adults found that stronger smoke free laws, tobacco price increases and greater exposure to mass media campaigns combined to independently explain 76% of the decrease in smoking prevalence from February 2002 to June 2011. For example, youth exposure to anti-tobacco media campaigns reduced the odds of current cigarette use by 15% and smokeless use by 30% compared to students with zero media exposure. Greater exposure reduced the odds of current cigarette use and smokeless use by 30% and 45%, respectively. Anti-smoking media campaigns help to shape social norms and institutional policies around smoking, which in turn change smoking behavior at the population level, including adult quit attempts. Several studies have found that youth are equally likely to report favorable responses to adult-targeted ads as to youth targeted ads, Studies from California, Massachusetts, and Australia demonstrate that exposure to adult-targeted mass media campaigns is associated with reduced smoking initiation and smoking behavior among youth. Even in countries where comprehensive tobacco control policies have been in effect for decades , intensive mass media campaigns have a positive additional influence on smoking behavior outcomes. Tobacco taxes are used to provide an annual revenue stream to support implementation of government media campaigns that consist of paid radio, television, billboard, internet and social media, and print advertising. Media campaigns with greater impact also include public relations campaigns for general market and population-specific communities, including various ethnic populations, young adult, and lesbian, gay, bisexual, transgender, and queer communities. The most successful application of the social norm change strategy took place in California, where in 1989 a statewide tobacco control program was implemented to transform the social environment where tobacco use is not socially desirable or acceptable. The key to the success of the California Tobacco Control Program has been its design as a broad-based campaign focused on reinforcing the nonsmoking norm aimed at the population as a whole – not just smokers or youth, for each element of the program, including the statewide hard hitting, evidence-based media campaign. Indeed, by focusing on adults through its comprehensive tobacco control program, California has achieved one of the lowest youth smoking rates in the United States. advertising bans are another important policy to denormalize tobacco use. Like large graphic warning labels and plain packaging, they are inexpensive for governments to implement, and generally apply to all products Point of sale tobacco display bans in Ireland and Australia were both followed by reduction in perceived smoking prevalence among youth and young adults, which reflects lower normalization of tobacco use. In contrast to media campaigns, which require regular appropriations and create ongoing opportunities for the tobacco industry to weaken, block, or eliminate funding, advertising bans, once enacted, are legally binding.Tobacco companies use product engineering to maximize consumption and profits. Large corporations have the scientific and technical capacity to undertake research and development programs that aim to identify which characteristics of a product to manipulate, and use sophisticated manufacturing processes to accentuate product features that maximize addictive potential. The cigarette companies invested heavily in their secret internal R&D departments to understand the addiction process, and modified their products to increase their addictiveness. Reviews of internal industry documents show that cigarette companies manipulate nicotine levels, cigarette length, chemical additives to alter nicotine absorption, improve the flavour of the smoke, reduce harshness, and increase puff intensity. They also use ventilated filters, manipulation of nicotine levels, and other product modifications to attract novice smokers and to increase addictive potential by optimizing nicotine delivery and dosing. Cigarette companies also designed their brands to meet psychological and psychosocial needs of consumers. In addition to attracting youth, product design technology was used to recruit and socially normalize smoking among women, African Americans, Latinos, Asians, LGBTQ, low income groups, and veterans. Cigarette companies have also taken advantage of weak cigarette testing protocols around the world to conceal the actual toxicity of their products to consumers and regulators. In the process of manufacturing cigarettes to enhance nicotine delivery, and so the addictiveness and sales of cigarettes, tobacco companies have reduced particle size and made many other design changes which , while good for the cigarette business, resulted in a more dangerous cigarette in 2014 than in 50 years earlier in 1964.