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Study reveals high environmental cost of tobacco

May 31st, 2017
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Smoking kills 7 million people a year, and it scars the planet through deforestation, pollution and littering.

http://edition.cnn.com/2017/05/31/health/tobacco-environment-who-report/

Details of the environmental cost of tobacco are revealed in a study released Wednesday by the World Health Organization, adding to the well-known costs to global health, which translate to a yearly loss of $1.4 trillion in health-care expenses and lost productivity.

From crop to pack, tobacco commands an intensive use of resources and forces the release of harmful chemicals in the soil and waterways, as well as significant amounts of greenhouse gases. Its leftovers linger, as tobacco litter is the biggest component of litter worldwide.

“Tobacco not only produces lung cancer in people, but it is a cancer to the lungs of the Earth,” said Dr. Armando Peruga, who previously coordinated the WHO Tobacco Free Initiative and now works as a consultant. He reviewed the new report for the WHO.

world-of-tobacco

Commercial tobacco farming is a worldwide industry that involves 124 countries and occupies 4.3 million hectares of agricultural land. About 90% of it takes place in low-income countries, with China, Brazil and India as the largest producers.

Because tobacco is often a monocrop — grown without being rotated with other crops — the plants and the soil are weak in natural defenses and require larger amounts of chemicals for growth and protection from pests.

“Tobacco also takes away a lot of nutrients from the soil and requires massive amounts of fertilizer, a process that leads to degradation of the land and desertification, with negative consequences for biodiversity and wildlife,” Peruga said.

The use of chemicals directly impacts the health of farmers, 60% to 70% of whom are women. This is especially prominent in low- and middle-income countries, where some compounds that are banned in high-income countries are still used.

300 cigarettes = one tree

Farming also uses a surprisingly large amount of wood, rendering tobacco a driver of deforestation, one of the leading causes of climate change.

About 11.4 million metric tonnes of wood are utilized annually for curing: the drying of the tobacco leaf, which is achieved through various methods, including wood fires.

That’s the equivalent of one tree for every 300 cigarettes, or 1.5 cartons.

This adds to the impact of plantations on forest land, which the study describes as a significant cause for concern, citing “evidence of substantial, and largely irreversible, losses of trees and other plant species cause by tobacco farming.”

Deadly gases

In 2012, 967 million daily smokers consumed approximately 6.25 trillion cigarettes worldwide, the WHO estimates.

“That means about 6,000 metric tonnes of formaldehyde and 47,000 metric tonnes of nicotine are released into the environment,” Peruga said.

Tobacco smoke contains about 4,000 chemicals, at least 250 of which are known to be harmful. It also contains climate-warming carbon dioxide, methane and nitrous oxides. “The combination of greenhouse gases from combustion is equivalent to about 1.5 million vehicles driven annually,” Peruga said.

Secondhand smoke is particularly deadly: It contains twice as much nicotine and 147 times more ammonia than so-called mainstream smoke, leading to close to 1 million deaths annually, 28% of them children.

Some of these pollutants remain in the environment (and our homes) as “third-hand smoke,” accumulating in dust and surfaces indoors, and in landfills. Some, like nicotine, even resist treatment, polluting waterways and potentially contaminating water used for consumption, the study notes.

Non-biodegradable litter

Tobacco litter is the most common type of litter by count worldwide.

“We calculate that two-thirds of every cigarette ends up as litter,” Peruga said.

The litter is laced with chemicals including arsenic and heavy metals, which can end up in the water supply. Cigarette butts are not biodegradable, and tossing one on the ground is still considered a socially acceptable form of littering in many countries.

The WHO estimates that between 340 million and 680 million kilograms of tobacco waste are thrown away every year, and cigarette butts account for 30% to 40% of all items collected in coastal and urban clean-ups.

“In addition to that, there are 2 million tons of paper, foil, ink and glue used for the packaging,” Peruga said.

A way forward?

Even though smoking is declining globally, it is increasing in some regions, such as the eastern Mediterranean and Africa. China is a world leader both in production (44%) and consumption, with 10 times more cigarettes smoked than in any other nation.

Every stage of the production of a cigarette has negative effects on the environment and the people who are involved in manufacturing tobacco products, even before the health of smokers and non-smokers is affected.

Although governments worldwide already collect $270 billion in tobacco taxes a year, the WHO suggests that increasing tax and prices is an effective way of reducing consumption and help development priorities in each country, adding that by collecting 80 cents more per pack, the global tax revenue could be doubled.

“Tobacco threatens us all,” WHO Director-General Margaret Chan said in a note. “It exacerbates poverty, reduces economic productivity, contributes to poor household food choices, and pollutes indoor air.”

Rise in Lung Adenocarcinoma Linked to ‘Light’ Cigarette Use

May 23rd, 2017
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A new study shows that so-called “light” cigarettes have no health benefits to smokers and have likely contributed to the rise of a certain form of lung cancer that occurs deep in the lungs.

http://journals.lww.com/oncology-times/blog/onlinefirst/pages/post.aspx?PostID=1618

For this new study, researchers at The Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC–James) and five other universities/cancer centers examined why the most common type of lung cancer, called adenocarcinoma, has increased over the past 50 years, rather than decreasing as smokers have been able to quit. Other types of lung cancer have been decreasing in relationship to fewer people smoking, but not lung adenocarcinoma. Because of this, lung adenocarcinoma is now the most common type of lung cancer.

Results confirm what tobacco-control researchers have suspected for years: There is no health benefit to high-ventilation (light) cigarettes–long marketed by the tobacco industry as a “healthier” option–and these cigarettes have actually caused more harm. Holes in cigarette filters were introduced 50 years ago and were critical to claims for low-tar cigarettes.

“This was done to fool smokers and the public health community into thinking that they actually were safer,” said Peter Shields, MD, Deputy Director of the OSUCCC–James and a lung medical oncologist. “Our data suggests a clear relationship between the addition of ventilation holes to cigarettes and increasing rates of lung adenocarcinoma seen over the past 20 years. What is especially concerning is that these holes are still added to virtually all cigarettes that are smoked today.”

The FDA was given the authority to regulate the manufacture, distribution, and marketing of tobacco products through the Family Smoking Prevention and Tobacco Control Act in 2009. Current regulations ban tobacco companies from labeling and marketing cigarettes as “low tar” or “light.” Study authors, however, say that given this new data, the FDA should take immediate action to regulate the use of the ventilation holes, up to and including a complete ban of the holes.

“The FDA has a public health obligation to take immediate regulatory action to eliminate the use of ventilation holes on cigarettes,” added Shields. “It is a somewhat complicated process to enact such regulations, but there is more than enough data to start the process. We believe that such an action would drive down the use and toxicity of conventional cigarettes, and drive smokers to either quit or use less harmful products. There are some open questions about unintended consequences for enacting a ban, which provides for an important research agenda.”

A team made up of lung oncology, public health, and tobacco regulation researchers conducted a comprehensive, multi-faceted analysis of existing literature that included chemistry and toxicology studies, human clinical trials and epidemiological studies of both smoking behavior and cancer risk. They studied scientific publications in the peer-reviewed literature and internal tobacco company documents.

Researchers hypothesized that the higher incidence rates of lung adenocarcinoma were attributable to the filter ventilation holes, which allow smokers to inhale more smoke that also has higher levels of carcinogens, mutagens and other toxins.

“The filter ventilation holes change how the tobacco is burned, producing more carcinogens, which then also allows the smoke to reach the deeper parts of the lung where adenocarcinomas more frequently occur,” explained Shields.

To date, all the scientific evidence involves the adverse impact of adding ventilation, but not removing it. Additional research is needed to confirm that the addictiveness of the cigarette or toxic exposures from cigarettes would not increase with elimination of the ventilation holes. The OSUCCC–James and researchers at the University of Minnesota, Roswell Park Cancer Institute, Virginia Tech, Harvard University and Medical University of South Carolina are conducting additional research to reconcile human biomarkers studies and smoke distribution/exposure in the lung.

How e-cigarette ads might sway teens to try tobacco products

May 22nd, 2017
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When non-smoking teens see ads for e-cigarettes, and are curious about the products advertised, perhaps even identifying with a favorite brand, they might also be more susceptible to taking up cigarettes, a new study finds.

http://www.businessinsider.com/r-how-e-cigarette-ads-might-sway-teens-to-try-tobacco-products-2017-5?IR=T

For the study, researchers showed a nationally representative sample of 10,751 U.S. teens advertisements for a wide variety of tobacco products including traditional cigarettes, cigars, chewing tobacco and e-cigarettes. Overall, the teens were more receptive to ads for e-cigarettes than other products and television ads were most likely to prompt brand recall.

“The imagery used by tobacco companies focuses on the aspirations of young people including having fun, being independent, sophisticated, socially accepted, popular, etc.,” said lead study author John Pierce of the University of California, San Diego.

“Those who have an emotive response to these aspirational images are more likely to see use of the product as a way to achieve their aspirations,” Pierce said by email. “It is hypothesized that in adolescents who are committed never smokers, recall of tobacco product advertising will be associated with first movement toward product use within a one-year time frame.”

Big U.S. tobacco companies are all developing e-cigarettes, battery-powered gadgets with a heating element that turns liquid nicotine and flavorings into a cloud of vapor that users inhale.

For the past decade, public health experts have debated whether the devices might help with smoking cessation or at least be a safer alternative to smoking traditional combustible cigarettes, or whether they might lure a new generation into nicotine addiction.

Fewer teens smoke today than a generation ago, but declines in traditional cigarette use have stalled and e-cigarettes have become increasingly popular in recent years. As of 2015, an estimated 16 percent of U.S. high school students used e-cigarettes, compared with about 9 percent for traditional cigarettes, according to the U.S. Centers for Disease Control and Prevention.

While television ads for traditional cigarettes have been illegal in the U.S. for decades, e-cigarette ads are currently allowed on TV, researchers note in Pediatrics.

In the study, Pierce and his colleagues examined how receptive or curious non-smoking teens were about different tobacco products and whether they had a favorite image or advertisement. They also looked at how susceptible the adolescents might be to trying tobacco products based on their ability to recall specific brands they saw in the ads.

The researchers showed each study participant a random selection of five ads each for cigarettes, e-cigarettes smokeless tobacco and cigars based on 959 different promotions that had recently been used to advertise these products.

Overall, 41 percent of the younger teens in the study and half of older adolescents were receptive to at least one tobacco advertisement, the study found.

Across each age group, teens were most receptive to ads for e-cigarettes, followed by traditional cigarettes and smokeless tobacco.

E-cigarette ads shown on television had the highest recall.

Compared to teens in the study who were not at all receptive to the ads, youth who had the highest level of engagement with the promotions were more than six times more likely to be susceptible to trying tobacco products, the study found.

The study isn’t a controlled experiment designed to prove whether or how ads may directly influence tobacco use.

Another limitation is that researchers didn’t have data to show whether or not teens actually used tobacco products after viewing these ads, the authors note.

Even so, the findings suggest that non-cigarette ads for tobacco-related products may be damaging for adolescent health, Rebecca Collins of Rand Corporation in Santa Monica, California, writes in an accompanying editorial.

“This study provides some very provocative data suggesting that the marketing of e-cigarettes, which is not regulated, might be leading to cigarette smoking among teens,” Collins said by email.

Comparative studies of the component composition of cigarettes and sticks “Parliament” with tobacco heating system iQOS

May 17th, 2017
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Effect of message congruency on attention and recall in pictorial health warning labels

May 16th, 2017
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Abstract

Objective

The nine pictorial health warning labels (PWLs) proposed by the US Food and Drug Administration vary in format and feature of visual and textual information. Congruency is the degree to which visual and textual features reflect a common theme. This characteristic can affect attention and recall of label content. This study investigates the effect of congruency in PWLs on smoker’s attention and recall of label content.

http://tobaccocontrol.bmj.com/content/early/2017/05/16/tobaccocontrol-2016-053615

Methods

120 daily smokers were randomly assigned to view either congruent or incongruent PWLs, while having their eye movements recorded. Participants were asked to recall label content immediately after exposure and 5 days later.

Results

Overall, the image was viewed more and recalled better than the text. Smokers in the incongruent condition spent more time focusing on the text than smokers in the congruent condition (p=0.03), but dwell time of the image did not differ. Despite lower dwell time on the text, smokers in the congruent condition were more likely to correctly recall it on day 1 (p=0.02) and the risk message of the PWLs on both day 1 (p=0.01) and day 5 (p=0.006) than smokers in the incongruent condition.

Conclusions

This study identifies an important design feature of PWLs and demonstrates objective differences in how smokers process PWLs. Our results suggest that message congruency between visual and textual information is beneficial to recall of label content. Moreover, images captured and held smokers’ attention better than the text.

Evaluation of Nicotine Pharmacokinetics

May 6th, 2017
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Smoking causes one in ten deaths globally, major new study reveals

Apr 5th, 2017
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Efforts to control tobacco have paid off, says study, but warns tobacco epidemic is far from over, with 6.4m deaths attributed to smoking in 2015 alone

https://www.theguardian.com/society/2017/apr/05/smoking-causes-one-in-ten-deaths-globally-major-new-study-reveals

One in 10 deaths around the world is caused by smoking, according to a major new study that shows the tobacco epidemic is far from over and that the threat to lives is spreading across the globe.

There were nearly one billion smokers in 2015, in spite of tobacco control policies having been adopted by many countries. That number is expected to rise as the world’s population expands. One in every four men is a smoker and one in 20 women. Their lives are likely to be cut short – smoking is the second biggest risk factor for early death and disability after high blood pressure.

The researchers found there were 6.4m deaths attributed to smoking in 2015, of which half were in just four populous countries – China, India, USA, and Russia.

Major efforts to control tobacco have paid off, according to the study published by the Lancet medical journal. A World Health Organisation treaty in 2005 ratified by 180 countries recommends measures including smoking bans in public places, high taxes in cigarettes and curbs on advertising and marketing.

Between 1990 and 2015, smoking prevalence dropped from 35% to 25% among men and 8% to 5% among women. High income countries and Latin America – especially Brazil which brought in tough curbs on tobacco – achieved the biggest drops in numbers of smokers.

But many countries have made marginal progress since the treaty was agreed, say the authors of the study from the Institute of Health Metrics and Evaluation at the University of Washington in the US. And although far more men smoke than women, there have been bigger reductions in the proportions of men smoking also, with minimal changes among women.

Senior author Dr Emmanuela Gakidou said there were 933m daily smokers in 2015, which she called “a very shocking number”. The paper focused only on those who smoke every day. “The toll of tobacco is likely to be much larger if we include occasional smokers and former smokers and people who use other tobacco products like smokeless tobacco. This is on the low end of how important tobacco is,” she told the Guardian.

There is much more that needs to be done, she said. “There is a widespread notion that the war on tobacco has been won but I think our evidence shows that we need renewed and sustained efforts because the toll of smoking in 2015 is much larger than most people would think, so we absolutely have a lot more to do. We need new and improved strategies to do it and a lot of effort and political will.”

Traditionally there have been far fewer women smoking around the world than men, but it was a huge problem for both, she said.

“There are some really worrisome findings – for example in Russia female smoking has increased in the last 25 years significantly. There are also some western European countries where about one in three women are smoking. So it is true globally that a lot fewer women smoke than men but there are some countries where it is a big problem for women,” she said.

Dr Kelly Henning of Bloomberg Philanthropies, which is committed to tobacco control and co-funded the study with the Bill and Melinda Gates Foundation, said: “I think the study highlights the fact that the work is not finished on tobacco. The good news is the decline in daily smoking among men and women … however there are still many smokers in the world and there is still a lot of work to do. I think we have to keep our eye on the issue and really do more.”

Countries with some of the highest death tolls such as China and Indonesia “really don’t need those health problems – they have so many other issues they are trying to address. But tobacco control is critically important in those places,” she said.

“China has more than a million deaths a year from smoking related diseases and China is only beginning to see the effects of their high male smoking rate. That is only one instance of what is expected to become an extremely major epidemic,” she said.

Writing in a linked comment, Professor John Britton from the University of Nottingham said: “Responsibility for this global health disaster lies mainly with the transnational tobacco companies, which clearly hold the value of human life in very different regard to most of the rest of humanity.” British American Tobacco, for instance, sold 665bn cigarettes in 2015 and made a £5.2bn profit.

“Today, the smoking epidemic is being exported from the rich world to low-income and middle-income countries, slipping under the radar while apparently more immediate priorities occupy and absorb scarce available human and financial resources,” he writes. “The epidemic of tobacco deaths will progress inexorably throughout the world until and unless tobacco control is recognised as an immediate priority for development, investment, and research.”

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Apr 5th, 2017
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Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/fulltext?elsca1=tlpr

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Apr 5th, 2017
by Editor.
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Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/abstract

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Graphical health warnings on cigarette packs found effective

Mar 26th, 2017
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A recently completed sample based study done in Bangladesh claims that the health warning labels describing the harmful effects of tobacco products using text and/or pictures are found to be effective.

Health warnings on cigarette packages are among the most prominent sources of information about the harms of smoking and tobacco use.

Indeed, even in high-income countries where millions of dollars are spent on anti-tobacco mass media campaigns, smokers still report getting information about the risks of smoking from cigarette packages almost as much as from television, and much more than from other sources such as print media.

Therefore, in a country such as Bangladesh, where very little information about the harms of tobacco use appears on television and other broadcast media, warning labels on tobacco packages represent an even more important opportunity for informing the public about the harms of tobacco. Given their tremendous reach and frequency of exposure, health warnings are an extremely cost-effective public health intervention compared to other tobacco prevention efforts such as paid mass media advertising – these came out of a sample-based survey.

Findings from the survey revealed, 98.1% of the respondents opined that they supported the current practice of bothside for pictorial/graphical health warnings (GHW) and 77.5% respondent informed that they thought that the current use of GHW of 50% of the cigarette pack for warnings was good enough to demotivate and reduce the use of tobacco products. Considering up to 50% of the cigarette pack, around 89% were supporting this.

The findings revealed – about 72.7% of the respondents reported that they felt very unpleasant to see the pictorial warning on the tobacco packets (74.1% in urban and 72.7% in rural areas). The survey also reported that the pictorial warning was very realistic to 65.6% of the respondents and extremely realistic to 17.0% respondent (18.8% in rural and 15.3% in urban areas).

The psychological impact of GHW on the respondents was also examined. 13.9% of the respondents were extremely worried and 61.7% were very worried to see the pictorial warning on the cigarette package.

In summary, the study found that the graphical health warnings (GHW) were realistic to provide health-related information and are very effective in creating an unpleasant feeling and sense of worriedness among the smokers to aware them regarding the harmful effects of smoking.

A good news that the study uncovered was 75.8% respondents tried to reduce or quit smoking after seeing the pictorial warning on the cigarette packet. The rate is 76.3% in rural and 75.3% in urban areas. 83.5% respondents reported that they tried to reduce or quit smoking habit to see the pictorial warning. 74.8% recommended to include
GHW in Biri, Gul and Jorda.

Moreover, 64.2% respondents recommended that government should take initiative for mass awareness and 85.5% recommended for more visual media (TV) coverage.

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