Cigarette Package Health Warnings and Interest in Quitting Smoking—14 Countries, 2008-2010 FREE

MMWR. 2011;60:645-651

2 tables omitted

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires health warnings on tobacco product packages sold in countries that ratified the WHO FCTC treaty.¹ These warnings are expected to (1) describe the harmful effects of tobacco use; (2) be approved by the appropriate national authority; (3) appear on at least 30%, and ideally 50% or more, of the package's principal display areas; (4) be large, clear, visible, and legible in the country's principal language(s); (5) have multiple, rotating messages; and (6) preferably use pictures or pictograms. To assess the effects of cigarette package health warnings on interest in quitting smoking among smokers of manufactured cigarettes aged ≥15 years, this report examines 2008-2010 data from the Global Adult Tobacco Survey (GATS) in 14 WHO FCTC countries. Among men, the prevalence of manufactured cigarette smoking ranged from 9.6% in India to 59.3% in Russia. Among men in 12 of the countries and women in seven countries, >90% of smokers reported noticing a package warning in the previous 30 days. The percentage of smokers thinking about quitting because of the warnings was >50% in six countries and >25% in men and women in all countries except Poland. WHO has identified providing tobacco health information, including graphic health warnings on tobacco packages, as a powerful “best buy” in combating noncommunicable disease.² Implementing effective warning labels as a component of a comprehensive approach can help decrease tobacco use and its many health consequences.

GATS is a nationally representative household survey conducted among persons aged ≥15 years using a standardized questionnaire, sample design, data collection method, and analysis protocol to obtain measures on key tobacco control indicators and ensure comparability across countries.* GATS was conducted once in each of the 14 countries during 2008-2010 by national governments, ministries of health, survey-implementing agencies, and international partners. In each country, a multistage cluster sample design is used, with households selected proportional to population size. Data are weighted to reflect the noninstitutionalized population aged ≥15 years in each country. For this analysis, current smokers of manufactured cigarettes† were asked whether they had noticed health warnings on a cigarette package in the previous 30 days, and whether the label led them to think about quitting smoking.‡ Responses were analyzed by sex and, within sex strata, by age and education level using bivariate analysis within individual countries. Differences in response estimates were considered statistically significant if 95% confidence intervals did not overlap. Overall response rates ranged from 65.1% in Poland to 97.7% in Russia.

The health warnings on cigarette packages in each country at the time GATS was conducted were described according to WHO FCTC guidelines.^3- 4 All GATS countries had warning labels on cigarette packages describing harmful effects of smoking at the time their survey was conducted. Four of the 14 countries (Brazil, Egypt, Thailand, and Uruguay) had pictorial warnings. A fifth country, India, introduced pictorial warnings in 2009, and had both text and pictorial warnings in circulation when GATS was conducted.

In all 14 countries, men were more likely to be cigarette smokers than women. Among men, prevalence of smoking ranged from 9.6% in India to 59.3% in Russia. Among women, prevalence of smoking was <25% in all countries and <2% in Bangladesh, China, Egypt, India, Thailand, and Vietnam.

In all countries except India (78.4%) and Mexico (83.5%), >90% of men reported noticing a health warning on a cigarette package. Among women, the percentage who noticed warnings was ≥75% in all countries except China (60.1%) and India (18.9%), and >90% in seven countries. In Bangladesh and Egypt, not enough women reported current smoking to calculate this percentage.

Smokers aged ≥65 years were less likely to notice warnings in Bangladesh (men), Brazil (men and women), Mexico (men), Philippines (men and women), Thailand (men), and Ukraine (men). Smokers who had not completed primary school education were less likely to have noticed warnings in Bangladesh (men), China (men and women), India (men), Mexico (women), Philippines (men and women), Turkey (women), and Vietnam (men).

Among smokers who noticed a package warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries (Bangladesh, Brazil, India, Thailand, Ukraine, and Vietnam) and >25% for men and women in all countries except one (Poland). Older male smokers were less likely to think about quitting in India and Uruguay; no other age group differences were noted.

Reported by: Roberta B. Caixeta, Adriana Blanco, Pan American Health Organization; Heba Fouad, Eastern Mediterranean Regional Office; Rula N. Khoury, European Regional Office; Dhirendra N. Sinha, Southeast Asian Regional Office; James Rarick, Western Pacific Regional Office; Edouard Tursan d’Espaignet, Douglas Bettcher, Tobacco Free Initiative, World Health Organization. GATS Collaborative Group. Sara A. Mirza, Rachel B. Kaufmann, Linda J. Andes, Glenda Blutcher-Nelson, Jason Hsia, Samira Asma, Terry Pechacek, Office on Smoking and Health, CDC. Corresponding contributor: Sara A. Mirza, CDC, smirza@cdc.gov, 770-488-6389.

CDC Editorial Note: This report is the first to provide survey results from all 14 countries that participated in GATS during 2008-2010. In these countries, the prevalence of smoking manufactured cigarettes varied widely and was more common among men. Warning the public about the dangers of tobacco is one of the strategies in WHO's MPOWER package to combat the tobacco epidemic.³ Most of these countries had met the minimum WHO FCTC health warning label criteria for cigarette packages at the time GATS was conducted. The majority of smokers noticed the health warnings, and in most countries >25% who noticed the warnings said they were led to think about quitting. These results indicate that package warnings can be effective for various populations and settings, including countries in which cigarette smoking prevalence currently is low.

To be effective, cigarette package warnings must capture smokers' attention and educate them about the health effects of tobacco use.⁵ The WHO FCTC guidelines provide parameters to accomplish these objectives by emphasizing features that increase the salience of warnings.^1,4 Prominent, pictorial warnings have been found to be the most effective in communicating the harms of smoking in several studies.^4,6 Smokers who perceive a greater health risk from smoking are more likely to think about quitting and to quit successfully.⁶ Further, evidence indicates that warnings are more likely to be effective if they elicit strong emotions, such as fear, seem personally relevant, and increase confidence in the ability to quit.^4,7 For example, a comparative analysis of responses to labels in Brazil, Mexico, and Uruguay found that the Brazilian warnings depicting human suffering had the strongest impact on thinking about quitting.⁸ Rotating warnings also is important because the impact of an individual label will decrease over time.⁵ Thus, a warning that is small in total size or font size, has been in circulation for a long time, or lacks informational content that generates an emotional response likely will not have the strongest possible impact.

Graphic warnings have the potential to reach those who do not notice or read text-only warnings; they also have the potential to better evoke emotional responses, increase knowledge of health risks, and reinforce motivations to quit smoking.⁹ Therefore, the WHO FCTC guidelines strongly encourage the use of graphic warnings.⁵ Low education level and older age were associated with not noticing warnings in some countries; virtually all of these countries had text-only warnings. Women were less likely to notice warnings than men in India, China, and Vietnam, countries where cigarette smoking prevalence is very low among women. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers and using other evidence-based tobacco control measures that reach populations that are not frequently exposed to cigarette packages.

Warnings were more effective at getting smokers to think about quitting in some countries than in others. Brazil and Thailand, countries with numerous prominent and graphic pictorial warnings in rotation, had among the highest prevalences of smokers thinking about quitting because of the warnings; these warnings received WHO's highest rating.³ However, reported thinking about quitting smoking also was relatively high in Bangladesh and Vietnam, where warnings covered less of the package and were text-only. The reasons for these findings are not immediately clear but might relate to the relative importance of package warnings among other contextual factors such as smokers' baseline knowledge about health risks, level of interest in quitting, and level of tobacco dependence, as well as concurrent tobacco control efforts and social norms surrounding tobacco use.⁷ Further research might be helpful in elucidating these factors and in determining the extent to which thinking about quitting because of warnings leads to quit attempts in GATS countries.

The findings in this report are subject to at least five limitations. First, all data were self reported, and social norms (e.g., unacceptability in some countries of women smoking) might have affected responses. Second, the education categories used in Brazil are not comparable to the categories used in this analysis, so Brazil's data were not evaluated for differences in prevalence by education. Third, this analysis included only smokers of manufactured cigarettes; however, other tobacco products (e.g., bidis, kreteks, hand-rolled cigarettes, waterpipes, and smokeless tobacco) are commonly used in India and other GATS countries. Fourth, the prevalence of smoking among women is low in some countries, so analyzing or interpreting results on the impact of package warnings among women was not possible. Finally, GATS was not designed to evaluate the effectiveness of individual health warning labels, and its core questions did not distinguish between the different labels in circulation in a country.

After GATS was conducted, Mexico, Philippines, Turkey, and Ukraine passed legislation requiring pictorial warning labels, and Thailand and Uruguay increased the size of their warnings. Worldwide, a majority of countries now have warnings on cigarette packages, but their features and strength vary.⁷ As of 2010, approximately 30 countries had pictorial warning labels covering at least 50% of the package,⁷ and additional countries were developing such labels.§ Future GATS will allow tracking of progress toward key tobacco use and control indicators. Smokers view their cigarette packages every time they remove a cigarette; therefore, the cigarette package represents a powerful vehicle to deliver health warnings directly to smokers. Nonsmokers and former smokers also can be discouraged from smoking by viewing comprehensive warnings.⁷

WHO has identified price increases; smoke-free policies; bans on tobacco advertising, promotion, and sponsorship; and providing tobacco health information via mass media campaigns and graphic health warnings to the public as tobacco “best buys”∥ because they can reduce tobacco initiation, help to prevent progression from initiation to addiction, increase cessation, decrease consumption, and change social norms.² Providing information about the dangers of using tobacco products with package warnings is a simple and cost-effective strategy to motivate quit attempts, thus helping to prevent the life-threatening effects of tobacco use.^9- 10

David Hammond, Univ of Waterloo, Ontario, Canada.

Warning the public about the dangers of tobacco is one of the key strategies in the World Health Organization's MPOWER package to combat tobacco use.

What is added by this report?

For the first time, data from all 14 Global Adult Tobacco Survey (GATS) countries are available. In these countries, the prevalence of smoking manufactured cigarettes varies widely and is more common among men. The majority of smokers noticed package warning labels. Among smokers who noticed a health warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries.

What are the implications for public health practice?

Strong health warning labels on cigarette packages are effective in motivating smokers to consider quitting. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers.

*Additional information and GATS country reports are available at http://www.cdc.gov/tobacco/global/spotlight/.

†Respondents who reported currently smoking manufactured (i.e., commercial) cigarettes on a “daily” or “less than daily” basis. The term “smokers” in this report refers to current smokers of manufactured cigarettes. Smokers of other tobacco products, such as bidis, kreteks, hand-rolled cigarettes, cigars, pipes, and waterpipes who did not also smoke manufactured cigarettes are not included in this analysis.

‡“In the last 30 days, did you notice any health warnings on cigarette packages?” and “In the last 30 days, have warning labels on cigarette packages led you to think about quitting?”

§Pictorial health warning labels currently in use are available at http://www.who.int/tobacco/healthwarningsdatabase/en/index.html.

∥A “best buy” is an intervention that is not only highly cost-effective but also inexpensive, feasible, and culturally acceptable to implement.