Writing is on the wall: Pictorial health warnings reduce tobacco use

Shobha Shukla / Bobby Ramakant *

More evidence from scientific research is pouring in to show that graphic pictorial health warnings on all tobacco products are very effective in preventing children and youngsters from starting to consume tobacco, and in encouraging existing tobacco users to quit the lethal addiction.

This is not only great news for public health and social justice, but is also another serious blow to the tobacco industry that is selling a product that kills one out of every two of its users as per the World Health Organization (WHO) - the United Nations health agency.

“These are the only two ways to reduce tobacco use: prevent young people from beginning tobacco use, and encourage existing users to quit. It is evident that the WHO's MPOWER Strategy is one of the most cost-effective ways for advancing tobacco control – and graphic pictorial health warning is one of them” said Dr Tara Singh Bam, a noted tobacco control leader and Asia Pacific Director of International Union Against Tuberculosis and Lung Disease (The Union).

Dr Bam was speaking as a faculty at the 2022 South Asia Tobacco Control Leadership Course of Johns Hopkins Bloomberg School of Public Health’s Institute for Global Tobacco Control.

Noted poet Elizabeth Barrett Browning had said “The Devil is most devilish when respectable.” Tobacco industry despite producing a product that kills and causes life threatening diseases, continues to be a legal entity. One wonders if any such industry- like the tobacco industry- can be a legal entity in today's times? That is why it is so essential to expose, delegitimise and hold this killer industry legally and financially liable for the damage it has caused to human life and our planet.

The nefarious designs of tobacco industry get further exposed as it is trying to stop governments from enforcing science- and evidence-backed public health policies to reduce tobacco use. Tobacco industry is resorting to all kinds of tactics from its ‘old playbook’ to delay, defeat, dilute, weaken or derail any effort to enforce vital public health interventions, such as the pictorial health warnings or plain packaging. From suing the governments in courts, to intimidation tricks, to other tactics, tobacco industry has done it all to try to derail governments' efforts of enforcing lifesaving public health policies.

Let us not forget that tobacco use kills over 8 million people worldwide every year. Each of these deaths could have been averted, and each of the life-threatening tobacco-related disease could have been prevented had #endTobacco become a reality years back.

Research published recently by Dr Tara Singh Bam, Anand B Chand and Bharat V Shah, “Evidence of the Effectiveness of Pictorial Health Warnings on Cigarette Packaging in Nepal” provides another solid evidence how pictorial/ graphic health warnings have helped save lives from deadly tobacco. Almost one third of the study participants were smokers and one in every ten was an ex-smoker. Nearly all of them (97.6%) believed that smoking was addictive.

The study found that four out of every five study participants believed that pictorial health warnings were very effective in motivating tobacco users to quit. 86.8% of the respondents said that these warnings were effective in convincing young people to not start tobacco use, and 89.1% said that ex-smokers were encouraged by these warnings to stay away from tobacco use (and not relapse into the grip of deadly addiction).

Almost all the study respondents (94%) agreed that these warnings were very effective in raising health awareness about dangers of tobacco use. Even 92.6% of the tobacco retailers supported the pictorial health warnings.

Among those respondents who were tobacco smokers, more than half of them (58%) said that they intended to quit smoking. Also, these warnings made them cut their tobacco intake by more than half (55%) - from an average of eleven cigarettes to five sticks per day. In addition, this study found that most of the tobacco smokers (77.8%) preferred to buy loose cigarette sticks and not full packs.

“Evidence from the study had triggered policy changes in Nepal, which included enlargement of the size of pictorial health warnings to 90% and the release of a notification to ban selling of loose cigarettes” said Dr Tara Singh Bam, one of the study researchers.

The two important study findings- that graphic pictorial health warnings prevent children and youth to not begin tobacco use, and encourage existing users to quit (and reduce daily tobacco intake)- are not only saving lives, but also harming the so-called ‘business interest’ of the tobacco industry.

“The devil’s voice is sweet to hear,” said Stephen King

If we look at the journey of Nepal in trying to adopt pro-people tobacco control laws and enforce them in the past two decades, we find that the tobacco industry has tried all its tricks of lies, deception and deceit in doing all-it-can to derail, defeat, weaken and/or dilute these efforts.

Nepal had signed the global tobacco treaty in 2003. Nepal ratified the global tobacco treaty (formally called the WHO Framework Convention on Tobacco Control) in 2006. No tobacco control policy came from the government till 2009 mainly because of the tobacco industry’s lobbying, political donations, and tobacco advertising, promotion and sponsorship which gave the industry more influence to block health policy.

A comprehensive tobacco control bill was eventually introduced in 2010 with 50% size of pictorial health warnings but the industry tried to influence the Ministries of Health and Law and managed to reduce the size of warnings from 50% to 30% in the draft bill. However, owing to intense efforts by public health champions and righteous parliamentarians, Nepal’s parliament adopted the 2011 Tobacco Control Bill with 75% size of pictorial health warnings.

A day after the regulation was signed in 2011, after a last minute intervention by the Prime Minister of Nepal, the tobacco industry and its front groups sued the government with twelve court cases against the pictorial health warnings. Excuses such as these warnings are ‘unconstitutional’ were given by the industry and its front groups. It was only in 2014 that the Supreme Court of Nepal finally cleared the pathway to enforce the pictorial health warnings.

In 2015, Nepal became the first country in the world to have the largest pictorial health warning policy (90% size). Currently Timor Leste has the largest pictorial health warnings of 92.5% size, worldwide. No prizes for guessing that the tobacco industry again sued the government of Nepal for trying to enforce pictorial health warnings of 90% size and even mobilized the US Chamber of Commerce to put more pressure on the government.

Plain packaging could be a reality in Nepal soon

Since then, there have been several attempts by the tobacco industry to influence ministers and government officials to reduce the size of pictorial health warnings. But as of now, public health champions are outsmarting the industry. Not just the second-largest size of pictorial health warnings continues to be a part of the tobacco control policy in Nepal, but a draft tobacco control bill is pending which recommends plain packaging – another proven strong public health policy.

“If we can hold the governments to account, then governments are more likely to hold the industry to account” rightly said Dr Tara Singh Bam. "We can hold tobacco industry accountable by improving government rules and regulations."

According to the WHO and the global tobacco treaty, plain packaging means restricting or prohibiting the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style.

It also implies the use of black and white, or two other contrasting colours, as prescribed by national authorities; nothing other than a brand name, a product name and/or manufacturer's name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; and standardized shape, size and materials.

No advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products is allowed. Plain packaging is currently pending approval in Nepal as part of a draft policy.

Every year, tobacco kills 24,800 people in Nepal. More than 3,500 of these lives are lost due to exposure to secondhand smoke. Two-thirds of people aged 15-69 years are exposed to secondhand smoke on a daily basis. Unless science and evidence-backed public health policies are strictly enforced, deadly tobacco will continue to take its toll and the world will continue to lose lives.