Smoking Visuals Decrease Habit

Graphic warnings on cigarette packs working, study says

SHERYL UBELACKER

Canadian Press/ Globe and Mail February 6, 2007

TORONTO — When it comes to changing the behaviour of smokers with warning labels on cigarette packages, it seems the bigger and more graphically in-your-face the better.

That's the conclusion of a four-year study that looked at differences in package warnings and their effects on smokers in Canada, Britain, Australia and the United States.

And it appears that Canada — with its large-sized warnings that include such photos as a mouthful of teeth with gums blackened by oral cancer and diseased lungs — leads the pack among the four countries in getting the anti-tobacco message across to smokers.

To conduct the study, published Tuesday in the American Journal of Preventive Medicine, researchers surveyed 15,000 adult smokers four times between 2002 and 2005. They asked a number of questions related to warnings on cigarette packages in participants' four respective countries, including whether they noticed them and how often they read them.

“We also asked if they noticed cessation information on packages, whether it makes them think about the health risks, as well as whether they've been stopped from having a cigarette because of the warnings or whether it's made them more likely to think about quitting,” said co-author David Hammond, an assistant professor of health studies and gerontology at the University of Waterloo.

“And what we find is that certainly when we started, the Canadian warnings performed far better than all of the others,” Mr. Hammond said from Waterloo, Ont.

In December, 2000, Canada was the first country in the world to put photos on cigarettes to go along with 16 different text messages in English and French, such as “Cigarettes Cause Lung Cancer” and “Cigarettes Cause Strokes,” that take up half the package, both front and back.

In 2002, when the first survey was conducted, Britain had six text warnings comprising just six per cent of packs, front and back; Australia's six were slightly larger (a quarter of the front and a third of the back); while the four U.S. warnings -- unchanged since 1984 -- are relegated to the side of the pack in small text.

In that first survey, warnings were noticed most often by Canadian smokers (60 per cent), followed by Australians (52 per cent), British smokers (44 per cent) and American tobacco users (30 per cent).

But Mr. Hammond said that since 2003, when Britain bumped up its text warnings to 16 and blew up their size to a third or more of the face and back of packages, “U.K. smokers are even more likely than Canadians to say that they look at and read the health warnings.”

The proportion of British smokers who reported noticing warnings “often” or “very often” soared to 82 per cent by the second survey.

“So what that tells us is . . . any time you refresh a health communication you're going to see an increase in the effectiveness, just because they're new.”

To adjust for the “novelty effect,” the researchers compared responses to Canadian warnings two and half years after they came out with those to British messages following the same period of time.

“What you find is that the Canadian warnings are either as good as or better than the U.K. warnings in every case,” said Mr. Hammond. “And in many ways it's common sense. The more vivid and engaging you make a warning, the more effective it is,” he said, pointing to how tobacco and other advertising campaigns employ pictures to sell their products.

“And so I think it really only makes sense to do the same when communicating health information.”

Roberta Ferrence, a senior scientist at the Centre for Mental Health and Addiction in Toronto, said the “innovative” study has produced a lot of important data on smokers' behaviour.

“Canada for most of the measures is the top or among the top responders with the highest proportion of people responding that it made them think, made them look and so forth.”

“And that's one of the key things that warnings are designed to do,” said Ms. Ferrence, executive director of the Ontario Tobacco Research Unit at the University of Toronto. She was not involved it the study.

While warnings are meant to affect tobacco users, “they can have an impact far beyond the actual smoker who's carrying the package,” she said.

“They create discussion. A parent can be sitting at the breakfast table and there's a pack on the table and a little kid says to him: ‘What does this mean Daddy?' when they see the picture.”

And for the smoker, the package is something they see “more than any billboard or anti-smoking ad or commercial,” she said. “This is something they see every time they have a cigarette.”

Ken Kyle, director of public issues for the Canadian Cancer Society, said the study provides further evidence of the effectiveness of large, picture-based warnings.

“It also provides additional rationale and encouragement to all countries that these warning labels should be adopted,” Mr. Kyle said in a statement. Several countries, including Brazil, Singapore and Thailand, have followed Canada's lead and introduced pictures on packages.

Mr. Hammond said picture warnings can also reach smokers with poor literacy skills compared to those with text-only warnings, an important factor among some Canadians and populations in countries with low education levels.

“I think looking forward to the next round of warnings in Canada. One way of making them more effective is to do things like include real stories from real smokers,” he said. “Conveying health information isn't just about listing diseases or giving statistics. It's about communicating risk in a meaningful way.”

Health Canada is conducting public consultations that may lead to new warning messages, a spokesman for the federal department said Monday. A proposal calls for 48 different warnings, with blocks of them displayed at any one time and rotated every two years.

“The proposed changes include creating messages of encouragement with information on the health benefits of quitting and tips on how to quit smoking,” said the spokesman. Revised warnings would likely not be implemented until late 2008 at the earliest.