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March, 2016:

Graphic warning labels and the demand for cigarettes


In 2010, the US Food and Drug Administration (FDA) proposed requiring tobacco companies to add graphic warning labels (GWLs) to cigarette packs. GWLs are large prominently placed warnings that use both text and photographic images to depict health risks of smoking. The companies challenged FDA’s authority on First amendment
grounds; the courts accepted that FDA could compel companies to add GWLs, but argued that FDA had not established that GWLs would significantly reduce smoking.

This paper adds new evidence on the question of whether GWLs would have reduced cigarette demand, by examining whether tobacco companies’ share prices fell unusually after news indicating a higher likelihood of having GWLs, and rose on the opposite news. Such findings would be expected if investors viewed GWLs as likely to
reduce cigarette demand.

An event-study approach is used to determine whether the stock prices of US tobacco companies rose or fell unusually after news events in the period when GWLs were proposed, finalised, challenged and withdrawn.

Tobacco companies’ stock prices indeed realised significant abnormal returns after GWL news, consistent with expected negative effects on cigarette demand. Our estimates suggest investors expected GWLs to reduce the number of smokers by an extra 2.4-6.9 million in the 10 years after the rule took effect.

These findings support the view that the GWLs proposed by FDA would have curbed cigarette consumption in the USA in an appreciable way.

Why US Big Tobacco Lobbies for E-Cigarettes

In the Golden State, home to healthy living, progressive politics and one of the lowest smoking rates in the nation, cigarettes can seem like a relic of the past, barred long ago from restaurants, bars and even some city parks.

And yet within the walls of California’s high-domed capitol, tobacco companies continue to wield surprising power. After a recent loss on a slate of tobacco-control bills headed to the governor’s desk, they are gearing up for a bigger test looming at the ballot this fall. With money to spend, they have threatened to sabotage a planned ballot measure to raise the cigarette tax.

The battles aren’t just in California. Despite the tobacco industry’s tarnished public image, it is operating a powerful and massive influence machine in statehouses from Salt Lake City to Topeka. With a playbook crafted nearly 20 years ago, the tobacco firms use direct lobbying, third-party allies and “grassroots” advocacy campaigns to spread model legislation and mobilize smokers against proposed regulations and tax hikes across the country. And they are taking up the mantle to defend a burgeoning electronic cigarette market as well.

Today, tobacco companies maintain some of the most extensive state lobbying networks in the country, totaling hundreds of lobbyists. Altria Group Inc. and Reynolds American Inc., which control the vast majority of the American tobacco market, are among just 21 entities that had registered lobbyists in every state at one point from 2010 through 2014, according to a Center for Public Integrity analysis of lobbyist registrations collected by the National Institute on Money in State Politics.

They’ve also given at least $63 million to state candidates, committees and ballot initiatives nationwide over the past five years.

“The tobacco companies never give up. They’re like the Borg.”

Their chief opponents, the American Cancer Society and American Heart Association, also have similarly broad lobbying networks, but the health associations have given hardly any money to state politicians.

With such extensive reach, tobacco companies have continued to fight off the simplest means of cutting smoking rates: higher taxes. Out of 24 states to propose higher cigarette taxes last year just eight passed increases, according to a tobacco industry group. And only Nevada, with a $1-per-pack hike, raised them by more than 50 cents. Health groups say incremental tax hikes of less than $1 are much less effective at cutting smoking rates because tobacco companies can easily counteract them with rebates and discounts.

E-cigarettes are the newest front in this multi-faceted war. While the Food and Drug Administration has announced plans to regulate e-cigarettes, for now it remains up to states to impose any regulations or taxes on the emerging products. So far, e-cigarette taxes have passed in only four states, while proposals have been defeated in at least 21 others. The tobacco industry, which is increasing its share of the new market, has also won language in at least 19 states in recent years making it harder to regulate and tax e-cigarettes under existing anti-smoking laws.

David Sutton, a spokesman for Altria, the parent company of Philip Morris, said his firm is generally opposed to taxes on its products and becomes politically active where necessary. Reynolds declined to answer specific questions for this article, pointing instead to its website, which says the company engages in lobbying and makes lawful political contributions to protect the interests of its business.

“The tobacco companies never give up,” said Stanton Glantz, a professor at the University of California, San Francisco’s Center for Tobacco Control Research and Education. “They’re like the Borg,” the indomitable alien horde of Star Trek lore.

‘Where tobacco bills go to die’

Nowhere has the tobacco fight been bigger, or more expensive, than in California, which has attracted at least two-thirds of tobacco companies’ state-level political donations since 2011. Public health advocates in the state say tobacco companies have used a potent combination of campaign contributions and behind-the-scenes lobbying to win enough friends in key places.

The strategy is most apparent on the Assembly’s Governmental Organization Committee, which oversees an odd combination of issues, including public records, state holidays, gambling, alcohol and tobacco.

Its chairman, Assembly member Adam C. Gray, a Democrat from Merced who has served on the committee since 2013, has accepted $88,100 in political contributions from Altria and Reynolds since he began campaigning for office in 2011, far more than any other member of the Legislature.

The two companies have directed some $390,000 in total to members who sat on that Assembly committee, a quarter of the money they’ve given to all legislative candidates and their committees in California over that period.

The large amount of money given to its members has prompted some to call it the “Juice Committee.” Health advocates call it “the committee where tobacco bills go to die.”

The committee has watered down or killed nearly every major tobacco bill that’s come through it in recent years, anti-smoking advocates say, including a recent attempt in July to regulate e-cigarettes.

In an unusual move, an identical e-cigarette bill and five other tobacco measures were reintroduced in a special session the following month to allow the legislation to sidestep Gray’s committee. They passed the Legislature this month, the first significant tobacco control bills to pass since the 1990s, a marked blow to the usually successful tobacco industry.

“Money has no influence on what goes on with policy. It just doesn’t,” Gray said. “Raising money to get into elected office is a component of what we have to do… And frankly, I’m a pretty aggressive fundraiser.”

Lawmakers and other Sacramento insiders point out that the direct contributions, which are subject to strict limits, are minimal compared to the money spent by independent political groups, which can raise and spend unlimited sums to support or oppose candidates as long as they do not coordinate with the candidates. Tobacco companies have given some $4.8 million to such independent political committees and parties in California since 2011, nearly three times as much as they gave directly to candidates.

“We provide contributions to candidates and elected officials who, in their work legislatively are at work on issues that have an impact on our business,” said Sutton, the Altria spokesman.

Altria and Reynolds have also spent some $5.4 million on lobbying in California since 2011. By comparison, the health groups that supported stronger tobacco regulation have spent some $2.7 million over the same period, though they lobby on many other issues as well.

“There’s a reason people spend money on that,” said Gary Winuk, who served for six years as the state’s lobbying and campaign finance enforcement officer before leaving for private practice last year. Winuk began his career working for a lawmaker on the Governmental Organization Committee decades ago, and said it was the behind-the-scenes maneuvering and power plays he saw there that made him want to work for the state ethics agency.

Preserving tobacco’s role

In 1999, R.J. Reynolds, now a division of Reynolds American, produced a memo describing a strategy to “preserve the company’s role and participation in U.S. commerce.” The document, archived at the University of California, San Francisco, included the company’s state lobbying objectives, chief among which was a plan to hire lobbyists in “as many states as possible,” as the company’s first “line of defense.”

Next was a commitment to make “appropriate political contributions and support key trade groups and allies,” adding, “there is an old saying in politics. ‘Money talks and bullshit walks’… It is especially true when dealing with tobacco issues.”

The third component of the lobbying strategy was to “execute grassroots mobilization of trade groups, smokers and other allies.”

Nearly two decades later, the company is still using the same roadmap. And smoking continues to be the leading cause of preventable deaths, killing nearly half a million Americans every year, according to the Centers for Disease Control and Prevention.

Reynolds and Altria employed a team of more than 450 state lobbyists in 2014, together retaining representatives everywhere but Nevada, according to an analysis of state records and data collected by the National Institute on Money in State Politics. They’ve also continued to work through trade organizations and advocacy groups.

When Kansas Gov. Sam Brownback proposed an increase of $1.50 per pack for traditional cigarettes last year to help fill a budget gap, Reynolds hired David Kensinger, who had served as the Republican governor’s chief of staff until leaving to work as a lobbyist in 2012. Weeks earlier, Kensinger was among a select group of insiders who received advance copies of Brownback’s proposed budget, which included the tax hike, before lawmakers did, according to The Wichita Eagle. Both Kensinger and Reynolds declined to comment on what happened.

Reynolds reported buying more than 350 meals for public officials and giving e-cigarettes to four House members in Kansas last year, according to state lobbying records, while Altria spent $283,000 on advertising and other outreach.

Related: The Flavor of Your Vape Might Not Be as Safe as You Think — But Tobacco Is Still Worse

Meanwhile, a group called Citizens for Tobacco Rights, an advocacy campaign run by Altria, blasted emails to its members, in one instance urging them to fight the tax by posting messages on the Facebook pages of their lawmakers. It’s a standard tactic of the group, which claimed to have generated more than 33,000 phone calls and 52,000 emails and letters to legislators in 2014.

Lawmakers eventually approved a tax increase of only 50 cents. Kansas continues to struggle with a $46 million budget deficit this fiscal year.

Protecting a smokeless future

Reynolds, too, has its own “grassroots” advocacy campaign, called Transform Tobacco. And as the name suggests, a new product is increasingly drawing the company’s focus.

The e-cigarette was invented in 2003 in China and started appearing in the US not long after. It’s gained an enthusiastic community of users, and by 2013 some 20 million adult Americans reported trying e-cigarettes, which vaporize a liquid such as propylene glycol mixed with flavorings and usually nicotine, the key addictive chemical in cigarettes, generally derived from tobacco.

E-cigarettes come in a huge range of varieties. One major brand charges about $10 for a disposable sleek black pen-like device that lasts about as long as two packs of cigarettes. But many “vapers” use so-called mods or tanks, bulkier refillable devices that can cost anywhere from $30 to well over $100. Users then buy separate vials of “e-juice,” with names like Cinnamon Crumble and Unicorn Milk, which typically sell for about $20 per 30-milliliter vial.

Sales of e-cigarettes in the US reached $3.3 billion last year, according to Wells Fargo Securities, and may surpass those of traditional cigarettes within a decade. While tobacco companies still control less than half of this market, they’ve begun buying up or starting their own e-cigarette brands in recent years, rapidly increasing their share.

Reynolds, a leader in the e-cigarette market, has promoted model legislation that says explicitly that e-cigarettes are not tobacco products. The Center for Public Integrity obtained a template copy of the model language that was circulated at one of dozens of youth tobacco prevention “dialogues” that Reynolds has held around the country in recent years for local health officials and advocates. The company offered to pay as much as $1,000, plus lodging, to those who attended, according to invitations the Center obtained.

So far, such model language has passed in at least 19 states, written into laws banning sales to minors. At least 11 of those passed laws that pull nearly verbatim from the Reynolds template, while at least eight others have enacted similar language that health groups say was promoted by Lorillard Tobacco, which Reynolds bought last year.

Pennsylvania and Michigan, the only states that do not prohibit sales to minors, have two bills pending with similar language.

Although Reynolds’ model language asserts that e-cigarettes are not tobacco products, the company’s own website describes its VUSE e-cigarette as exactly that.

The most immediate effect of the bills is to protect e-cigarettes from existing tobacco control programs and taxes. E-cigarette proponents say the alternate definitions are warranted because the products do not burn tobacco. But health groups warn that the definitions pushed by the industry will harm the public.

“You build this infrastructure for regulating e-cigarettes on a faulty promise that they’re somehow a healthy product,” said Timothy Gibbs, a lobbyist for the American Cancer Society Cancer Action Network in California and a chief shepherd of the tobacco control bills there. “While the scientific consensus is that they may be safer than traditional cigarettes, that doesn’t mean they’re safe.”

It seems likely that “vaping” is less harmful than smoking. The question is by how much. The Centers for Disease Control says e-cigarettes “generally emit lower levels of dangerous toxins” than cigarettes, but can also release carcinogenic compounds and heavy metals. The agency says that e-cigarettes could provide a public health benefit if they lead smokers to quit. But it suggests that isn’t happening — about three-quarters of e-cigarette users also smoke cigarettes — and the products may be harmful if they prolong smokers’ addiction.

“They knew 50 years ago what they were doing. And they’re doing it again today.”

State Sen. Mark Leno, a Democrat who sponsored the recently approved California bill that defines e-cigarettes as tobacco products, said their popularity among youth — some 2.4 million middle and high school students were using e-cigarettes nationally in 2014 — means the devices present a new health crisis. He likens today’s fight to what happened with smoking in the mid-20th century, when tobacco companies began a decades-long campaign to discredit the emerging science showing the lethal and addictive qualities of cigarettes.

“They knew 50 years ago what they were doing,” Leno said. “And they’re doing it again today.”

Reynolds declined to answer questions about the model legislation or the dialogues, pointing instead to a company webpage that explains its “transforming tobacco” initiative, which promotes youth prevention programs and argues that smoke-free products, including e-cigarettes, can reduce “the death and disease caused by cigarettes.” Health advocates say the company has insidiously used this campaign in its efforts to win legislation protecting e-cigarettes from harsher regulation.

Altria declined to answer whether it has lobbied in favor of the language.

Vapers fight back

In California, the full weight of state government has gotten behind a campaign to rein in e-cigarette use. Last year, the state public health department warned of the dangers of the product and recommended strict regulations, launching a website and ad campaign called Still Blowing Smoke. This month, with passage of Leno’s bill, the Legislature took a big step in that direction.

Yet the state has met formidable resistance not just from the tobacco industry but also from a fledgling industry of smaller e-cigarette manufacturers and retailers backed by a passionate movement of vapers. Mobilized around the country, these e-cig aficionados have protested in Salt Lake, circulated petitions in Washington state and flown to the nation’s capital to push their position with congressional leaders.

Within hours of the launch of the state’s Still Blowing Smoke campaign last March, for example, another website called NOT Blowing Smoke popped up, using a similar font and logo but blasting the department for peddling misinformation.

Stefan Didak, a 44-year-old software engineer and co-president of the Northern California chapter of the Smoke-Free Alternatives Trade Association, a vaping industry group, had learned that the health department was planning the campaign and spent 36 hours holed up in his home office, a dark room with an array of 12 monitors, 14 computers and a plastic rack holding dozens of e-cigarettes.In a savvy guerrilla tactic, he beat the department to registering social media accounts, so the Still Blowing Smoke Facebook page and Twitter handle lead to content by NOT Blowing Smoke.

“Yeah, that was fun,” Didak said from his home in Oakley, a city on the eastern edge of the Bay Area. Didakwore a black NOT Blowing Smoke T-shirt and held a black mod e-cigarette, the type preferred by hard-core vapers. The blinds were drawn and the air held the faint sweet odor emitted by his mod, which he sucked on periodically, blowing out thick clouds of “ripe strawberry shortcake” flavored vapor.

SFATA Executive Director Cynthia Cabrera says her group was not affiliated with the counter-campaign. The association hired lobbyists in Sacramento to oppose Leno’s bill and has urged Gov. Jerry Brown, a Democrat, to issue a veto.

Didak said that bill would drive small vape shops and liquids manufacturers out of the state — or out of business — by applying the various licensure and regulatory requirements that apply to tobacco. As someone who quit cigarettes thanks to vaping, he said that restricting the industry would harm public health.

Didak and other vapers stress that they are not “big tobacco” and that SFATA does not receive money from tobacco companies. “We don’t regard them as part of us,” Didak said.

In coming months, however, they’ll be on the same side.

A bold threat

Whether Brown signs Leno’s e-cigarette bill, part of the package of six tobacco measures the Legislature passed this month, an expensive fight looms in California’s freewheeling ballot initiative process.

A coalition of health and labor groups, with support from liberal billionaire Tom Steyer, is currently gathering signatures for a ballot initiative that would hike the state’s cigarette tax by $2 and levy an equivalent tax on e-cigarettes. At 87 cents, California’s current tax is well below the national average.

Yet that effort may be in jeopardy.

This month, a lobbyist for Altria sent a bold threat in an email first published by The Sacramento Bee: the company plans to try to repeal some of the tobacco bills it had opposed by putting them before voters in a referendum on this fall’s ballot. In a calculating political move, it also threatened to corner the all-important ballot measure market of professional signature gatherers by paying top dollar. That could price out the health groups from their cigarette tax campaign and imperil all other measures trying to make the ballot, including an extension of a key tax increase known as Proposition 30.

“When we hit the street with referendum paying $10 per signature, Prop 30 is dead as well as $2 a pack tax,” warned in an email Altria lobbyist George Miller IV, son of the former Democratic California congressman. “We will have every signature gatherer on an exclusive. Just letting you know so you can’t say you were not warned.”

The health groups say they could be forced to either up their own prices, which are now about $4 per signature, or rally volunteers instead.

“We’re appalled but not surprised,” said Gibbs, the Cancer Society lobbyist, adding that tobacco companies have a history of particularly ruthless tactics. “They seem to be throwing a fit.”

Miller did not respond to requests for comment. Sutton, Altria’s spokesman, called Miller’s message “simply a friendly heads-up email between long-time colleagues.”

No matter whether Altria follows through on its threat, the coming months are sure to see many millions of dollars spent on all sides. Health groups have already raised $4 million for their campaign. During two previous attempts to raise cigarette taxes at the ballot, in 2006 and 2012, Reynolds and Altria spent more than $113 million and defeated both measures.

CTA Letter to the Ombudsman on Tobacco Control in Hong Kong

Dear Ombudsman,

So in a nutshell, tobacco control in Hong Kong is in a major dilemma of its own making due to a lack of political will.

The Financial Secretary should stick to playing with food trucks, watching French movies and drinking middle class coffee and make decisions within his sphere of ability.

Generally, that means if he has to spend less on hospital beds and medical treatment by taking simple preventative measures he should have done so already a long time ago instead of pandering to this nauseous lethal industry.

He should be guided by the expertise of COSH, not ignore it and make decisions accordingly.

He is poorly funding an organisation (COSH) with taxpayer money then ignoring their expertise and advice. That is poor Value for Money in any Auditor’s eyes.

He should not have the power of GOD to ignore preventative health measures that he is obliged to follow through, under the FCTC ratified treaty legal international instrument lodged with the UN.

All senior Government officials, Legco members, District Councillors are paid from the public purse. As such they are public servants/officials under the Laws of Hong Kong.

They all have a Duty of Care to the Health, Welfare and well-being of the people of Hong Kong – they do not have a Duty of Care to pander to and act as ‘honorary advisors’ to the Tobacco companies/fronts who are public enemy number 1 who see youth nicotine addiction as ‘growth’.

This deliberate obstinacy borders in Misconduct in Public Office and suggests an ulterior motive for not doing what should be done.

People are dying due to obstinate bad decision making in a sphere of knowledge outside of that individual’s capabilities, or it seems he prefers the tobacco company corporate taxes ahead of such preventative measures?

His only response is to build more hospital beds to house the sick and dying from what is a totally preventable disease source – smoking highly addictive genetically enhanced nicotine tobacco.

Note that COSH has a deputy director of Health who sits on its Board; so the FS is ignoring the Health Bureau and COSH advice by not having excise tax increases above inflation and yearly preventative increases
that will stop youth being addicted to nicotine.

Meanwhile the leadership of the Health Bureau is apathetic, seemingly without political will to stand up to the FS for what is right, and they should be standing up for the rights of citizens and passive smokers to be free from the tobacco scourge.

The Tobacco Control Office is massively understaffed and needs at least 500% its current manpower to operate properly over three shifts and with preventative patrols. That is for you to establish whether the Health Bureau mandated for regular tax increases or has the FS repeatedly denied them? Either way TCO need 5-fold increase to allow patrols. If people cannot go to pubs and smoke as they can now, they will quit. They will not sit at home smoking and avoid socializing with their friends.

The Liquor licensing board is likewise apathetic and has all along the sole legal power to stop smoking in licensed premises immediately or make licensees lose their licences. They chose the wrong option and need castigating.

I sat in Legco having made a presentation and listened to a member of FEHD bleat how tobacco control was not part of her job and hence unwilling to help.

That seems to have carried through.

At the same meeting I asked a senior woman health official how she intended to enforce smoking laws against visitors, especially those from the Mainland, since they have 21 days to pay the ticket, hence will be long gone.

“We will post a demand note to their provided address (Chou En Lai , tin shack, paddy field 17, Wong Pat An village , Hunan)’ was her daft answer.

The flawed Legislation was wrong from the outset but HKG took what it could or the Liberals were going to stretch out even the initial legislation.

The laws need to be amended to put the onus on licensees’ enforcement to create a level playing field for the hospitality industry: immediately TCO would grow by an number of 13,000.

The laws need to cover cigars and pipe tobacco and shisha tobacco – at present only cigarettes have to be tested for tar and nicotine content.

Laws need to be in place to stop smokers crowding around entrances and windows to premises.

Structures with a roof need to be added as non-smoking areas such as the exits of the arrival and departure halls at the airport, since their sides are open, like an escalator (which is legislated).

Non-smoking in OSA garden areas needs legislation – after all the laws were enacted to protect people in the workplace.

Meanwhile why do we not have Plain packaging , larger graphic warnings, vendor licences to sell tobacco, compliance checking, point of display bans ? A good question for the Health Bureau.

With efficiently staffed TCO officers patrolling nightspots and blackspots the police can concentrate on other aspects of their job; with tobacco costing $120 a packet youngsters cannot start smoking, older smokers will quit and blue collar families will have more income for food instead of addiction and passive smoking in the cramped home.

Meanwhile Government should be pursuing a lawsuit against Big Tobacco as in the Master Settlement Lawsuit action in USA. The merchants of death do not have a gangrenous leg to stand on.

The usual worldwide tobacco company mantra ‘ more tax means more smuggling’ is usually applied. Well in Canada the Government arrested tobacco executives for conspiracy to defraud and sent them to jail. It is a known proven and admitted fact in tobacco documents online and director admissions that the tobacco companies smuggle their own products through their loose supply chains to defeat anti tobacco Government measures, addict youth at a cheaper price and importantly to them, enhance their bottom line, no matter at what cost to society.

Yours sincerely,
James Middleton

Download (PDF, 436KB)

Gruesome pictorial warnings could save millions of smokers’ lives

On March 16, 2016, last day of the two sessions of the National People’s Congress and the Chinese People’s Political Consultative Conference, Duan Tieli, deputy director of the State Tobacco Monopoly Administration (STMA), also a deputy to the NPC, told the media that China had no plans to increase pictorial warnings on cigarette packages since such photos of smokers’ darkened teeth and rotten lungs or images of skulls were not consistent with “traditional Chinese cultural values.”

Duan may not have known but in 2008, when WHO conducted its third session of signature countries that had signed the Framework Convention on Tobacco Control (FCTC), a great majority of those countries had already passed the resolution that cigarette packages should carry pictorial warnings as required.

Meanwhile, however, a Chinese delegate representing the STMA argued that Chinese cigarette packages can only display pictures of famous mountains and great rivers to reflect traditional Chinese historical and cultural heritage, instead of showing ugly pictures to humiliate and disrespect the Chinese people.

As soon as this remark was made, the speaker was booed off-stage and that night all deputies at the session passed a resolution to give China the Dirty Ashtray Award, stating that China had not supported the requirement of displaying pictorial warnings on cigarette packages and that it had mocked the FCTC rules by showing beautiful pictures at the cost of public health.

Furthermore, by May 2015, 85 countries globally had already adopted the practice of showing pictorial warnings on cigarette packages, including many Asian countries and regions such as Nepal, Sri Lanka, Mongolia, Thailand, Singapore, Malaysia, Vietnam, Pakistan, Hong Kong and Taiwan, etc. China has been left far behind.

Peng Liyuan, the first lady of China, has made her concerns and commitment for tobacco control public. She became an ambassador for tobacco control in 2009. In 2012, to support World No-Tobacco Day activities, Peng and Bill Gates were dressed in red shirts printed with a slogan against passive smoking. They joined hands to promote the rights of non-smokers and practices for a smoke-free environment.

Actually, displaying pictorial warnings on cigarette packages happens to be the most effective, direct, and expense-saving approach to help smokers quit smoking. This is also required by the FCTC, in order to confront all smokers with a graphic design that discourages smoking.

In March 2009, I attended the 14th World Conference on Tobacco or Health in Mumbai, India. At the site, I was interviewed by reporters and presented my idea at a discussion group session that pictorial warnings would serve three distinct and meaningful purposes, “to discourage smokers from smoking themselves; to make it improper for them to share cigarettes with others; and to render it impossible to use cigarettes as a gift to VIPs, superiors, and others.”

Consequently, the practice of having pictorial warnings on cigarette packages is a must. One thing remains clear and that is the Chinese government and its legislative branch should work together to make this happen and thus deliver urgently needed services to the people to improve their health conditions.

Finally, the STMA, under the jurisdiction of the Ministry of Industry and Information Technology, should fulfill its mission of tobacco control instead of looking to boost its own profits.

Tobacco control, which benefits China and its people as a whole, deserves a great push immediately and forcefully. Adding pictorial warnings on cigarette packages is a necessity and an effective approach to facilitate the whole process.

The author is a tobacco control specialist and current affairs commentator for CCTV News. Follow us on Twitter @GTopinion

France orders plain packaging for cigarettes; Japan Tobacco to appeal

PARIS – France published a decree on Tuesday that requires cigarette manufacturers to introduce plain packaging by the end of the year.

Japan Tobacco International immediately said it would challenge the measure.

The publication of the decree was the culmination of government efforts launched in 2014 to require tobacco firms to sell cigarettes in packages decorated with neither logos nor distinctive coloring.

But Japan Tobacco International’s French subsidiary quickly announced it would challenge the decree before the Council of State.

“The introduction of plain packages doesn’t take into account the damage it does to the property rights of companies, in particular intellectual property rights,” JTI France’s Corporate Relations and Communications Director Benoit Bas said in a statement.

That is the argument tobacco companies have used against the introduction of plain packaging in Australia.

In 2012, Australia became the first country to mandate plain packaging for cigarettes in a bid to reduce smoking rates, and is being followed by Ireland and Britain as well as France.

The British ban on logos and branding on cigarette packets goes into force in May, but tobacco firms have filed a legal challenge.

The appeal by JTI before the Council of State, the nation’s supreme court for administrative justice, will not suspend the introduction of plain packages.

Tobacco firms lost their legal cases in Australia and failed to have the matter accepted for international arbitration.

They also failed to overturn an EU law allowing member states to impose plain packaging.

20 myths about smoking that will not die

Originally published as two columns on The Conversation, we bring you the definitive list of 20 myths about smoking that will not die by Simon Chapman, University of Sydney

Across forty years I’ve come to recognise many factoid-driven myths about smoking that just won’t die. If I asked for a dollar each time I had to refute these statements, I’d have accumulated a small fortune.

Their persistence owes much to their being a vehicle for those who utter them to express unvoiced but clear sub-texts that reflect deeply held beliefs about women, the disadvantaged, mental illness, government health campaigns and the “natural”.

Let’s drive a stake through the heart of ten of the most common myths.

1. Women and girls smoke more than men and boys

Women have never smoked more than men. Occasionally, a survey will show one age band where it’s the other way around, but from the earliest mass uptake of smoking in the first decades of last century, men streaked out way ahead of women.

In 1945 in Australia, 72% of men and 26% of women smoked. By 1976, men had fallen to 43% and women had risen to 33%.

As a result, men’s tobacco-caused death rates have always been much higher than those of women. Women’s lung cancer rates, for example, seem unlikely to reach even half the peak rates that we saw among men in the 1970s.

Currently in Australia, 15% of men and 12% of women smoke daily.

But what about all the “young girls” you can see smoking, I’m always being told. In 2014, 13% of 17-year-old male high school students and 11% of females smoked. In two younger age bands, girls smoked more (by a single percentage point).

Those who keep on insisting girls smoke more are probably just letting their sexist outrage show about noticing girls’ smoking than their ignorance about the data.

2. Quit campaigns don’t work on low socioeconomic smokers

In Australia, 11% of those in the highest quintile of economic advantage smoke, compared with 27.6% in the lowest quintile. More than double.

So does this mean that our quit campaigns “don’t work” on the least well-off?

Smoking prevalence data reflect two things: the proportion of people who ever smoked, and the proportion who quit.

If we look at the most disadvantaged group, we find that a far higher proportion take up smoking than in their more well-to-do counterparts. Only 39.5% have never smoked compared with 50.4% of the most advantaged – see table 9.2.6).

When it comes to quitting, 46% of the most disadvantaged have quit compared to 66% of the least disadvantaged (see table 9.2.9).

There is a higher percentage of the disadvantaged who smoke mainly because more take it up, not because disadvantaged smokers can’t or won’t quit. With 27.6% of the most disadvantaged smoking today, the good news is that nearly three-quarters don’t. Smoking and disadvantage are hardly inseparable.

3. Scare campaigns ‘don’t work’

Countless studies have asked ex-smokers why they stopped and current smokers about why they are trying to stop. I have never seen such a study when there was not daylight between the first reason cited (worry about health consequences) and the second most nominated reason (usually cost).

For example, this national US study covering 13 years showed “concern for your own current or future health” was nominated by 91.6% of ex-smokers as the main reason they quit, compared with 58.7% naming expense and 55.7% being concerned about the impact of their smoking on others.

If information and warnings about the dire consequences of smoking “don’t work”, then from where do all these ex-smokers ever get these top-of-mind concerns? They don’t pop into their heads by magic. They encounter them via anti-smoking campaigns, pack warnings, news stories about research and personal experiences with dying family and friends. The scare campaigns work.

4. Roll-your-own tobacco is more ‘natural’ than factory made

People who smoke rollies often look you in the eye and tell you that factory made cigarettes are full of chemical additives, while roll-your-own tobacco is “natural” – it’s just tobacco. The reasoning here that we are supposed to understand is that it’s these chemicals that are the problem, while the tobacco, being “natural”, is somehow OK.

This myth was first turned very unceremoniously on its head when New Zealand authorities ordered the tobacco companies to provide them with data on the total weight of additives in factory made cigarettes, roll-your-own and pipe tobacco.

For example, data from 1991 supplied by WD & HO Wills showed that in 879,219kg of cigarettes, there was 1,803kg of additives (0.2%). While in 366,036kg of roll-your-own tobacco, there was 82,456kg of additives (22.5%)!

Roll-your-own tobacco is pickled in flavouring and humectant chemicals, the latter being used to keep the tobacco from drying out when smokers expose the tobacco to the air 20 or more times a day when they remove tobacco to roll up a cigarette.

5. Nearly all people with schizophrenia smoke

It’s true that people with mental health problems are much more likely to smoke than those without diagnosed mental health conditions. A meta-analysis of 42 studies on tobacco smoking by those with schizophrenia found an average 62% smoking prevalence (range 14%-88%). But guess which study in these 42 gets cited and quoted far more than any of the others?

If you said the one reporting 88% smoking prevalence you’d be correct. This small 1986 US study of just 277 outpatients with schizophrenia has today been cited a remarkable 1,135 times. With colleagues, I investigated this flagrant example of citation bias (where startling but atypical results stand out in literature searches and get high citations – “wow! This one’s got a high number, let’s quote that one!”).

By googling “How many schizophrenics smoke”, we showed how this percolates into the community via media reports where figures are rounded up in statements such as, “As many as 90% of schizophrenic patients smoke.”

Endlessly repeating that “90%” of those with schizophrenia smoke does these people a real disservice. We would not tolerate such inaccuracy about any other group.

6. Everyone knows the risks of smoking

Knowledge about the risks of smoking can exist at four levels:

Level 1: having heard that smoking increases health risks.
Level 2: being aware that specific diseases are caused by smoking.
Level 3: accurately appreciating the meaning, severity, and probabilities of developing tobacco related diseases.
Level 4: personally accepting that the risks inherent in levels 1–3 apply to one’s own risk of contracting such diseases.

Level 1 knowledge is very high, but as you move up the levels, knowledge and understanding greatly diminish. Very few people, for example, are likely to know that two in three long term smokers will die of a smoking caused disease, nor the average number of years that smokers lose off normal life expectancy.

7. You can reduce the health risks of smoking by just cutting down

It’s true that if you smoke five cigarettes a day rather than 20, your lifetime risk of early death is less (although check the risks for one to four cigarettes a day here).

But trying to “reverse engineer” the risk by just cutting down rather than quitting has been shown in at least four large cohort studies such as this one to confer no harm reduction.

If you want to reduce risk, quitting altogether should be your goal.

8. Air pollution is the real cause of lung cancer

Air pollution is unequivocally a major health risk. By “pollution”, those who make this argument don’t mean natural particulate matter such as pollen and soil dusts, they mean nasty industrial and vehicle pollution.

The most polluted areas of Australia are cities where pollution from industry and motor vehicle emissions are most concentrated. Remote regions of the country are the least polluted, so if we wanted to consider the relative contributions of air pollution and smoking to smoking-caused diseases, an obvious question to ask would be “does the incidence of lung cancer differ between heavily polluted cities and very unpolluted remote areas?”

Yes it does. Lung cancer incidence is highest in Australia in (wait for this …) in the least polluted very remote regions of the country, where smoking prevalence happens also to be highest.

9. Smokers should not try to quit without professional help or drugs

If you ask 100 ex-smokers how they quit, between two-thirds and three-quarters will tell you they quit unaided: on their final successful quit attempt, they did not use nicotine replacement therapy, prescribed drugs, or go to some dedicated smoking cessation clinic or experience the laying on of hands from some alternative medicine therapist. They quit unaided.

So if you ask the question: “What method is used by most successful quitters when they quit?” The answer is cold turkey.

Fine print on this English National Health Service poster states a bald-faced lie by saying that “There are some people who can go cold turkey and stop. But there aren’t many of them.” In the years before nicotine-replacement threapy and other drugs were available, many millions – including heavy smokers – quit smoking without any assistance. That’s a message that the pharmaceutical industry was rather not megaphoned.

10. Many smokers live into very old age: so it can’t be that harmful

In just the way that five out of six participants in a round of deadly Russian roulette might proclaim that putting a loaded gun to their head and pulling the trigger caused no harm, those who use this argument are just ignorant of risks and probability.

Many probably buy lottery tickets with the same deep knowing that they have a good chance of winning.

Ten more myths about smoking that will not die

There’s plainly a big appetite for smoking myth busting, so here are 10 more.

1. Today’s smokers are all hard core, addicted smokers who can’t or won’t give up

This claim is the essence of what is known as the “hardening hypothesis”: the idea that decades of effort to motivate smokers to quit has seen all the low-hanging fruit fall from the tree, leaving only deeply addicted, heavy smokers today.

The key index of addicted smoking is the number of cigarettes smoked per day. This creates a small problem for the hardening hypothesis: in nations and states where smoking has reduced most, the average number of cigarettes smoked daily by continuing smokers has gone down, not up. This is exactly the opposite of what the hardening hypothesis would predict if remaining smokers were mostly hard core.

2. Smoking is pleasurable

Repeated studies have found that around 90% of smokers regret having started, and some 40% make an attempt to quit each year. There’s no other product with even a fraction of such customer disloyalty.

But I’m always amused at some die-hard smokers’ efforts explain that they smoke for pleasure and so efforts to persuade them to stop are essentially just anti-hedonistic tirades. Many studies have documented that the “pleasure” of smoking centres around the relief smokers get when they have not smoked for a while. The next nicotine hit takes away the discomfort and craving they have been experiencing.

This argument is a bit like saying that being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.

3. Light and mild cigarettes deliver far less tar and nicotine to the smoker than standard varieties

Several nations have outlawed cigarette descriptors such as “light” and “mild” because of evidence that such products do not deliver lower amounts of tar and nicotine to smokers, and so are deceptive.

The allegedly lower yields from cigarettes labelled this way resulted from a massive consumer fraud.

Cigarette manufacturers obtained these low readings by laboratory smoking machine protocols which took a standardized number of puffs, at a standardized puff velocity. The smoke inhaled by the machine was then collected in glass “lungs” behind the machine and the tar and nicotine weighed to give the readings per cigarette.

But the companies didn’t tell smokers two things. So-called light or mild cigarettes had tiny, near-invisible pin-prick perforations just on the filter (see picture). These holes are not covered by the “lips” or “fingers” of the laboratory smoking machine, allowing extra air to be inhaled and thus diluting the dose of tar and nicotine being collected.

But when smokers use these products, two things happen. Their lips and fingers partially occlude the tiny ventilation holes, thus allowing more smoke to be inhaled. Smokers unconsciously “titrate” their smoking to obtain the dose of nicotine that their brain’s addiction centres demand: they can take more puffs, inhale more deeply, leave shorter butt lengths or smoke more cigarettes.

Today, where use of these descriptors has been stopped, the consumer deception continues with the companies using pack colours to loudly hint to smokers about which varieties are “safer”.

4. Filters on cigarettes remove most of the nasty stuff from cigarettes

We’ve all seen the brown stain in a discarded cigarette butt. But what few have seen is how much of that same muck enters the lungs and how much stays there.

This utterly compelling video demonstration shows how ineffective filters are in removing this deadly sludge. A smoker demonstrates holding the smoke in his mouth and then exhales it through a tissue paper, leaving a tell-tale brown stain. He then inhales a drag deep into his lungs, and exhales it into a tissue. The residue is still there, but in a much reduced amount. So where has the remainder gone? It’s still in the lungs!

5. Governments don’t want smoking to fall because they are addicted to tobacco tax and don’t want to kill a goose that lays golden eggs

This is perhaps the silliest and most fiscally illiterate argument we hear about smoking. If governments really want to maximise smoking and tax receipts, they are doing a shockingly bad job of it. Smoking in Australia has fallen almost continuously since the early 1960s. In five of the 11 years to 2011, the Australian government received less tobacco tax receipts than it did the year before (see Table 13.6.6).

Plainly, as smoking continues to decline, diminishing tax returns will occur, although this will be cushioned by the rising population which will include some smokers.

In the meantime, tobacco tax is a win-win for governments and the community. It reduces smoking like nothing else, and it provides substantial transfer of funds from smokers to government for public expenditure.

Those of us who don’t smoke do not squirrel away what we would have otherwise spent on smoking in a jam jar under the bed. We spend it on other goods and services, benefiting the economy too.

6. Most smokers die from smoking caused diseases late in life, and we’ve all got to die from something

Smoking increases the risk of many different diseases, and collectively these take about ten years off normal life expectancy from those who get them.

Smoking is by far the greatest risk factor for lung cancer. In Australia, the average age of death for people with lung cancer is 71.4 (see Table 4.2), while life expectancy is currently 80.1 for men and 84.3 for women.

This means that, on average, men diagnosed with lung cancer lose 8.7 years and women 12.9 years (mean 10.8 years). Of course, some lose many more (Beatle George Harrison died at just 58, Nat King Cole at 45).

If a 20-a-day smoker starts at 17 and dies at 71, 54 years of smoking would see 394,470 cigarettes smoked. At ten puffs per cigarette, that’s some 3.94 million point-blank lung bastings.

It takes about six minutes to smoke a cigarette. So at 20 a day, smokers smoke for two hours each day. Across 54 years, that’s a cumulative 1,644 days of smoking (4.5 years of continual smoking if you put it all together).

So by losing ten years off life expectancy, each cigarette smoked takes about 2.2 times the time it takes to smoke it off the life expectancy that might otherwise have been enjoyed.

7. Smokers cost the health system far more than the government receives from tobacco tax

In June 2015, a senior staff member of Australian libertarian Senator David Leyonhjelm, Helen Dale tweeted:

In Australia, a now old report looking at 2004/05 data estimated the gross health care costs attributable to smoking “before adjustment for savings due to premature death” were $A1.836 billion. In that financial year, the government received $A7,816.35 billion in customs and excise duty and GST on tobacco.

Someone who thought that the fiscal ledger was all that mattered in good government might conclude from this that smokers easily pay their way and perhaps we should even encourage smoking as a citizen’s patriotic duty.

With smokers being considerate enough to die early, these noble citizens lay down their lives early and thus contribute “savings due to premature death” like failing to draw a state pension or needing aged care services late in life.
Philip Morris notoriously gave this advice to the new Czech government in 1999.

Other assessments, though, might well point to the values inherent in such assessments. History’s worst regimes have often seen economically non-productive people as human detritus deserving death. Primo Levi’s unforgettable witnessing of this mentality in Auschwitz comes to mind.

8. Big Tobacco is starting to invade low-income nations, now that smoking is on the wane in the wealthiest nations

Sorry, but US and British manufacturers have been aggressively marketing cigarettes in places such as China since the early years of last century. These collectable posters show many featuring Chinese women.

The large populations, the often lax tobacco-control policies and the higher corruption indexes of many low- and middle-income nations makes many of these nirvanas for Big Tobacco.

There are fewer more nauseating experiences than reading the corporate social responsibility reports of tobacco transnationals and then seeing how they operate in smokers’ paradises such as Indonesia. This documentary says it all.

9. Millions of cigarette butts on the world’s beaches leach lots of toxic chemicals into oceans

Cigarette butts are the most discarded items in all litter. Every year uncounted millions if not billions are washed down gutters in storm water and find their way into rivers, harbours and oceans. Cigarette filters and butts contain toxic residue and experiments have shown that placing laboratory fish in containers for 48 hours with leachate extracted from used cigarette butts, 50% of the fish die. From this, we sometimes hear people exclaim that cigarette butts are not just unsightly, but they “poison the oceans”.

But a confined laboratory container does not remotely mirror real life exposures in oceans or rivers. There are some 1,338,000,000 cubic kilometers of water in the world oceans, so the contribution of cigarette butts to the toxification of all this could only excite a homeopath.

If we want to reduce tobacco litter, we need not wander into such dubious justifications. The best way by far is to keep reducing smoking. Industry attempts at portraying themselves as corporately responsible by running dinky little clean-up campaigns or distributing personal butt disposal canisters avoids their efforts to keep as many smoking as possible.

10. Tobacco companies care deeply about their best customers dying early

Naturally, all businesses would rather their customers lived as long as possible so that the cash registers can keep ringing out long and loud. Tobacco companies wish their products didn’t kill so many, but worship the god nicotine for its iron grip on so many.

Visit any tobacco transnational’s website and you will find lots of earnest and caring talk about the companies’ dedication to doing all they can to reduce the terrible harm caused by their products. All the major companies have now invested heavily in electronic cigarettes, so isn’t this a sign that they taking harm reduction seriously?

It might be if the same companies were showing any sign of taking their feet off the turbo-drive accelerator of opposing effective tobacco control policies. But they are doing nothing of the sort. All continue to aggressively attack and delay any policy like tax hikes, graphic health warnings, plain packaging and advertising bans wherever in the world these are planned for introduction.

For all their unctuous hand-wringing about their mission to reduce harm, they are all utterly determined to keep as many smoking as possible. Big Tobacco’s business plan is not smoking or ecigarettes. It’s smoking and ecigarettes. Smoke when you are able to, vape when you can’t. It’s called dual use and some 70% of vapers are doing just that. The tragedy now playing out in some nations is that too many gormless tobacco control experts are blind to this big picture.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

Implications of Graphic Cigarette Warning Labels on Smoking Behavior

Implications of Graphic Cigarette Warning Labels on Smoking Behavior: An International Perspective


Graphic warning labels (GWLs) have been developed as a representative non-price policy to block such marketing. This study investigated the current state and effect of the global introduction of GWLs and examines the future tasks related to GWLs. We systematically reviewed literatures on GWL and a tobacco control strategy in the past fifteen years. The policy of enforcing GWLs has spread globally based on the Framework Convention on Tobacco Control. GWLs are more effective than text warnings and are implemented in over 70 countries. The policy has showed the impact of GWLs as a preventive effect on adolescents’ smoking, inducement of smoking cessation, reduction in the amount of tobacco smoked, and reduction in smoking rates. The success of an anti-smoking policy can manifests itself as an effect of individual policies, the rise of tobacco prices, and the introduction of GWLs.


Packaging is tobacco companies’ primary means of marketing due to the strengthening of anti-smoking policy worldwide.1 Graphic warning labels (GWLs) have been developed as a cost-effective policy for simultaneously inhibiting such marketing and conveying information on the health risks incurred by smoking. The introduction of GWLs is effective for attracting smokers’ attention and publicizing the harmfulness of tobacco.2,3 Article 11 of the Framework Convention on Tobacco Control (FCTC) recommends the introduction of the GWL for at least 50% of the packet cover and enforces countries directly involved to comply within three years of adopting the Convention. In addition, the third general assembly of the FCTC in 2008 recommended the introduction of plain packaging to prevent the advertising effect through tobacco packs.4 Packing can have an effect of deluding consumers and promoting the sales of tobacco. The present study systematically reviews the current state and effect of the global introduction of GWLs and examines the future tasks related to GWLs.


The GWLs were first introduced to Canadian consumers in 2001. Subsequently, the FCTC took effect in 2005 as an international effort to reduce deaths and illnesses due to tobacco, and rapidly increased the number of countries adopting GWL. In particular, Canada established the Tobacco Products Information Regulations in 2000 based on the Tobacco Act.5 As a result, tobacco packaging with GWLs, anti-smoking warning messages, and explanations on the emission and composition of toxic substances became mandatory.5 In the early introduction of GWLs, the area on the package was extended to at least 30% of cigar, pipe tobacco, hookah, and smokeless tobacco packaging and to at least 50% for ordinary tobacco packs.5

GWLs swiftly spread worldwide. For example, the Thai government in 2004 passed a law making it mandatory to attach GWLs on both the front and back sides, extending to 50% of the entire cigarette packs.6 The sizes of the GWLs have expanded to no less than 85% of a cigarette pack. The mandatory attachment of GWLs worldwide exceeds 82.5% in Australia and 80% in Uruguay. Obviously, the tobacco industry has strongly opposed restrictions through GWLs. The industry has argued that the harmfulness of tobacco is widely known already, and that the attachment of GWLs to the packaging violates trademark rights and copyrights and can incite the production of counterfeit tobacco.6 Such debates have led to scientific discussions on whether the future introduction of GWLs will reduce smoking rates.

It is reported that tobacco packaging has a greater marketing effect than do other consumer goods because the packaging is not discarded immediately after it has been opened.1,5 The packing is exposed to those around the tobacco users a countless number of times until all of the contents have been used up. In other words, adoption of GWLs is intended more to stop tobacco companies’ from marketing than to provide health education to consumers by publicizing the risks and harmfulness of smoking. In fact, tobacco companies have developed tobacco packs with ‘cool’ or ‘feminine’ images to attract the attention of the young and women and to strengthen their brand images through stealth marketing.5 Consequently, some tobacco companies have lawsuits against the US Food and Drug Administration.7 This has led to debates on the introduction of GWL effects.

In spite of the many debates, the effects of GWLs on smokers’ attitudes toward smoking seem clear. The fear and anger generated when smokers are exposed to GWLs have a positive effect on smoking cessation and a negative effect on smoking.8 According to a recent study published in Tobacco Control, the strength of emotional responses generated after exposure to GWLs determined the effect of GWLs.9 When functional magnetic resonance imaging of neural responses generated after exposing smokers to GWLs were analyzed, the images aroused strong emotional reactions, which increase cognitive efforts that accompany information processing.10 This increases the memory of the images and reduces the desire to smoke.9,10 In other words, smokers exposed to GWLs exhibited more fear and a stronger intention to quit smoking than did smokers exposed to simple warning messages.

According to data announced by the Canadian Cancer Society in 2014, GWLs have been introduced to seventy-six countries worldwide as of 2015. After all members of the European Union adopt GWLs in 2016, GWLs will be implemented in at least ninety-four countries.5 GWLs were adopted by only five countries in the early 2000s, twenty-nine countries from 2006 to 2010, and forty-two countries from 2011 to 2015.5 GWLs are scheduled to be adopted by eighteen countries in 2016. Thus, insertion of the GWLs on tobacco packaging can be seen as a global trend.


The introduction of GWLs may induce smokers to quit smoking, and thus lowers tobacco consumption. In the case of Canada, smoking cessation motivation is reported to have increased among half of the smokers since the adoption of GWLs.5,11 In Australia, GWLs have aroused smoking cessation motivation among 60% of the smokers.12 Subsequently, one-third of the smokers have attempted to quit smoking. Likewise, in Thailand, the intention to quit smoking has increased among half of the smokers since the introduction of GWLs.13 An increase in smokers’ smoking cessation efforts and actual smoking cessation rates after the adoption of the GWL has affected tobacco consumption. In the case of Singapore, 28% of smokers reported smoking fewer cigarette because of GLWs in 2004.14 In addition, the adoption of GWLs has inhibited the number of new smokers and induced current smokers to quit smoking.15 Importantly, a major cause in the reduction of tobacco consumption lies in the inhibition by new smokers, including adolescents. According to reports on the population conducted in Australia and Canada, the smoking prevention effects of GWLs amount to a maximum of 60%.16,17 The introduction of GWLs more effectively inhibits an increase in the number of smokers than do warning messages. This has been confirmed for adolescents in European countries such as Greece.18

Second, the introduction of GWLs may decrease the overall smoking rates. In the case of price policy, smoking rates drop according to an increase in tobacco prices.19 However, tobacco consumption often returns to the normal consumption rate with the passage of time. Yet, the adoption of GWLs exhibits a continuous smoking decrease effect in comparison with price policy.20 In the case of Canada, the introduction of GWLs is estimated to have led to a drop in the number of smokers by approximately 12% to 19%.19,20 Of course, predicting a uniform decrease in smoking rates is difficult because the strength of graphic labels and the presence of other warning messages differ by country. Nevertheless, according to research by Huang et al.,19 smoking rates will decrease by a maximum of 5% if Canada’s GWLs are applied to the United States. What is important is that the adoption of GWLs generally leads to a continuous drop in smoking rates. In the case of Turkey, men’s smoking rate was approximately 44% in 2008 and dropped to 39.0% in 2010 and 37.3% in 2012 due to the introduction of GWLs.21

Third, the introduction of GWLs leads to additional effects such as the conveyance of health information from the perspective of health communication. In Australia and Thailand, the ability to convey information has been strengthened when warning messages were combined with GWLs.12 In the case of China and Mexico, senior citizens, women, and low socioeconomic status groups have been shown to recognize information more effectively on diseases that are caused by smoking through GWLs.2,22 In addition, according to the results of comparative studies among countries, tobacco consumers more accurately recognized diseases due to cigarette smoke substances (3.4 times as much for carbon monoxide and 3.8 times as much for potassium cyanide) and smoking (2.7 times as much for impotence and 1.6 times as much for both strokes and cancer occurrence) with GWLs.23 The correct awareness of health information has a potential effect of inducing smokers to voluntarily enhance the use of smoking cessation services. In the case of the Netherlands, the number of calls to smoking cessation hotlines has increased by 3.5 times since the introduction of GWLs.24 Brazil and New Zealand have shown similar effects.24–26

Fourth, the adoption of GWLs may create social benefits in diverse ways. However, when smoking rates drop because of GWLs, governments experience a drop in tax. The introduction of GWL policies decreases related diseases, and thus ultimately benefits society. In the case of Canada, the adoption of GWLs has extended the life span, which has yielded a net benefit of approximately four billion dollars.27 In the case of the United Kingdom, the introduction of GWLs has resulted in a decrease in the number of smokers by 0.5% and a net benefit of 206.29 million pounds because of an increase in the economic value of the living population and the curtailment of medical expenses.28 In Australia, a net benefit of 2.9 billion dollars has been generated because of a decrease in smoking rates, extension of the life span, improvement in health, the curtailment of medical expenses, and an increase in the consumption of non-tobacco products.29


GWLs are cited as the most cost-effective policy from a diverse set of anti-smoking policies.30 GWLs are an evidence-based policy whose effect has been proven by countries that have already adopted them. Consequently, when GWLs are implemented with price policy that raises tobacco prices, they are expected to effectively decrease smoking rates and the number of new smokers, and prevent adolescent smoking.18 However, several tasks remain.

First is the task of effective application by the FCTC. The FCTC stipulates within the scope allowed by the countries respective constitutions, ‘comprehensive ban actions,’ for the advertisement, and sales promotion and support for tobacco.4 For example, India implements comprehensive ban actions on advertisements, sales promotions, and support regarding tobacco in accordance with the FCTC.4 Tobacco advertisements are prohibited on the broadcast media such as television and radio, and publications such as magazines and newspapers. On the other hand, signatories of the FCTC have an obligation to implement this clause by modifying their respective laws and institutions related to the packaging and labeling of tobacco products within three years of convention ratification.4 Consequently, the states parties have included health warning messages and graphic labels on at least 30% of the packaging and have strongly restricted tobacco packaging, which has been used as a means for marketing tobacco. For example, Australia in October 2011 passed a law that prohibits the inclusion of advertising statements, images, and company logos on cigarette packs.4 This law applies so-called ‘plain packaging,’ and thus requires to uniformize the color of all cigarette packs as drab dark brown and to include chilling images demonstrating the harm of smoking instead of advertising images and company logos.4 It is fair to say that the warnings are important for providing useful information to consumers.

Second, developing various and effective GWLs in a sociocultural context and smoking characteristics for each country is necessary. GWLs mainly affect smokers through fear, which can yield disparate effects according to the conveyed contents, themes, and messages. Consequently, the effectiveness and effect of GWLs on smokers for each country must be analyzed meticulously.

Third, longitudinal studies comparing long-term changes in smoking rates before and after the introduction of GWLs need to be conducted. In addition, scientifically reviewing both price policies and various non-price policies that yield the greatest smoking cessation effect is necessary. Such a task will continuously prove the long-term effect of a policy, and thus secure the validity of and justification for the introduction of the policy and expand related future policies. Economic evaluation and cost-benefit analysis must also be conducted. To meticulously grasp the policy effect, it is necessary to consider whether the goals have been achieved by adopting GWLs and who are to be the objects of persuasion. Smokers vs. non-smokers, heavy smokers vs. occasional smokers, and adolescents vs. adults are possible. The effect of GWLs may be most dramatic for occasional smokers or adolescents in their early to mid-teenaged years that have not yet started to smoke rather than heavy smokers who have formed the habit.


This paper attempted to summarize what is happening globally in terms of GWLs, how effective the implementation of GWLs is on decreasing tobacco rates, and what the next steps are for GWLs around the world. The success of an anti-smoking policy can manifests itself as an effect of individual policies, the rise of tobacco prices, and the introduction of GWLs. Success need to be evaluated as an integrated effect of diverse policies that includes the rise of tobacco prices and the extension of non-smoking areas.



No potential conflicts of interest were disclosed.


1. Wakefield M, Morley C, Horan JK, Cummings KM. The cigarette pack as image: new evidence from tobacco industry documents. Tob Control. 2002;11(Suppl 1):I73–80. doi: 10.1136/tc.11.suppl_1.i73. [PMC free article] [PubMed] [Cross Ref]
2. Strasser AA, Tang KZ, Romer D, Jepson C, Cappella JN. Graphic warning labels in cigarette advertisements: recall and viewing patterns. Am J Prev Med. 2012;43:41–7. doi: 10.1016/j.amepre.2012.02.026. [PMC free article] [PubMed] [Cross Ref]
3. Hammond D. Health warning messages on tobacco products: a review. Tob Control. 2011;20:327–37. doi: 10.1136/tc.2010.037630. [PubMed] [Cross Ref]
4. U.S. Department of Health and Human Services . The health consequences of smoking–50 years of progress: a report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
5. Canadian Cancer Society . Cigarette Package Health Warnings: International Status Report. 4th ed. Ottawa: Canadian Cancer Society; 2014.
6. Vathesatogkit P, Charoenca N. Tobacco control: lessons learnt in Thailand. Indian J Public Health. 2011;55:228–33. doi: 10.4103/0019-557X.89938. [PubMed] [Cross Ref]
7. R.J. Reynolds Tobacco Company. Lorillard Tobacco Company. Commonwealth Brands, Inc. Liggett Group LLC. Santa Fe Natural Tobacco Company, Inc. (Plaintiffs) United States district court for the District of Columbia. United States Food and Drug Administration, Margaret Hamburg, Kathleen Sebelius (Defendants) Civil Case No. 11-1482 (RJL), document 59. Ordered February 29, 2012.
8. Byrne S, Katz SJ, Mathios A, Niederdeppe J. Do the ends justify the means? A test of alternatives to the FDA proposed cigarette warning labels. Health Commun. 2015;30:680–93. doi: 10.1080/10410236.2014.895282. [PubMed] [Cross Ref]
9. Wang AL, Romer D, Elman I, Turetsky BI, Gur RC, Langleben DD. Emotional graphic cigarette warning labels reduce the electro-physiological brain response to smoking cues. Addict Biol. 2015;20:368–76. doi: 10.1111/adb.12117. [PMC free article] [PubMed] [Cross Ref]
10. Wang AL, Lowen SB, Romer D, Giorno M, Langleben DD. Emotional reaction facilitates the brain and behavioural impact of graphic cigarette warning labels in smokers. Tob Control. 2015;24:225–32. doi: 10.1136/tobaccocontrol-2014-051993. [PMC free article] [PubMed] [Cross Ref]
11. Cunningham R. Cigarette package warning size and use of pictures: international summary. Ottawa: Canadian Cancer Society; 2009.
12. Borland R, Yong HH, Wilson N, Fong GT, Hammond D, Cummings KM, et al. How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction. 2009;104:669–75. doi: 10.1111/j.1360-0443.2009.02508.x. [PMC free article] [PubMed] [Cross Ref]
13. International Tobacco Control Policy Evaluation Project . ITC Thailand survey summary. Waterloo, Institute for Population and Social Research, Mahidol University Salaya, and Thai Health Promotion Foundation; 2009.
14. Health Promotion Board . Graphic health warnings on tobacco packaging inspire smokers to quit the habit. Singapore: Health Promotion Board; 2004.
15. Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ. 2009;87:640–3. doi: 10.2471/BLT.09.069575. [PMC free article] [PubMed] [Cross Ref]
16. Australian Government Department of Health and Ageing . Evaluation of the effectiveness of the graphic health warning on tobacco product packaging. Canberra: Australian Government Department of Health and Ageing; 2008.
17. Environic Research Group Ltd . The health effects of tobacco and health warning messages on cigarette packages: survey of youth-wave12 surveys. Ottawa: Health Canada; 2007.
18. Vardavas CI, Connolly G, Karamanolis K, Kafatos A. Adolescents perceived effectiveness of the proposed European graphic tobacco warning labels. Eur J Public Health. 2009;19:212–7. doi: 10.1093/eurpub/ckp015. [PubMed] [Cross Ref]
19. Huang J, Chaloupka FJ, Fong GT. Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis. Tob Control. 2014;23(Suppl 1):i7–12. doi: 10.1136/tobaccocontrol-2013-051170. [PMC free article] [PubMed] [Cross Ref]
20. Azagba S, Sharaf MF. The effect of graphic cigarette warning labels on smoking behavior: evidence from the Canadian experience. Nicotine Tob Res. 2013;15:708–17. doi: 10.1093/ntr/nts194. [PubMed] [Cross Ref]
21. Organization for Economic Cooperation and Development (OECD) OECD Health Statistics: Non-medical determinants of health: Tobacco consumption. Geneva: OECD; 2014.
22. Fong GT, Hammond D, Jiang Y, Li Q, Quah AC, Driezen P, et al. ITC China Project Team Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study. Tob Control. 2010;19(Suppl 2):i69–77. doi: 10.1136/tc.2010.036483. [PMC free article] [PubMed] [Cross Ref]
23. Hammond D, Fong GT, McNeill A, Borland R, Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15(Suppl 3):iii19–25. doi: 10.1136/tc.2005.012294. [PMC free article] [PubMed] [Cross Ref]
24. Willemsen MC. The new EU cigarette health warnings benefit smokers who want to quit the habit: results from the Dutch Continuous Survey of Smoking Habits. Eur J Public Health. 2005;15:389–92. doi: 10.1093/eurpub/cki061. [PubMed] [Cross Ref]
25. Cavalcante TM. Labelling and packaging in Brazil (WHO tobacco free initiative toolkit series) Geneva: World Health Organization; 2003.
26. Li J, Grigg M. New Zealand: new graphic warnings encourage registrations with the quitline. Tob Control. 2009;18:72. doi: 10.1136/tc.2008.027649. [PubMed] [Cross Ref]
27. Health Canada . Regulatory impact analysis statement: tobacco products information regulations. Ottawa: Canada Gazette Directorate; 2000.
28. United Kingdom Department of Health . The introduction of picture warnings on tobacco packs: final regulatory impact assessment. London: United Kingdom Department of Health; 2007.
29. Applied Economics . Cost-benefit analysis of proposed new health warnings on tobacco products. Canberra: Commonwealth Department of Health and Ageing; 2003.
30. Hammond D. Tobacco packaging and labeling policies under the U.S. Tobacco Control Act: research needs and priorities. Nicotine Tob Res. 2012;14:62–74. doi: 10.1093/ntr/ntr182.

QUANTUM LEAP: MPs’ remarkable manifesto BACKING the tobacco industry

The latest report of the Committee on Subordinate Legislation, tabled in the Lok Sabha on March 15, is a remarkable document.

The committee was supposed to deliberate rules relating to the size of pictorial health warnings on tobacco packs, but it has ended up being an unabashed manifesto of the tobacco industry.

Cigarette companies, pan masala and gutka manufacturers, and beedi kings should be grateful to our lawmakers for so eloquently articulating their standpoint – be it the denial of a link between tobacco and cancer, or loss of business due to cigarette smuggling.

While glorifying the tobacco industry as an employment and revenue generator, the report makes a mockery of health concerns and desperately attempts to downplay – and even deny – the health impacts of tobacco.

While doing so, the MPs have accepted arguments put forth by the tobacco industry as ‘evidence’, but have dubbed research studies quoted by the Ministry of Health about tobacco-related diseases or tobacco’s link with cancer as ‘claims’.

The health ministry has been asked to produce more evidence about health impacts, while questionable surveys about health warnings being ineffective cited by the tobacco industry have been extensively quoted.

Parliamentarians want us to be convinced that tobacco is vital for the Indian economy and people’s wellbeing.

The report says: “Tobacco plays a very important role in economy supporting crores of livelihood and generating significant tax revenues and foreign exchange.”

It describes the central excise rate for cigarettes as “high and discriminatory” – an argument cigarette companies advance after every Budget.

As for its main task – examining the 2014 notification on increasing the size of pictorial warnings – the panel feels that larger health warnings on cigarette and beedi packs will be “too harsh” and will result in “flooding of the market with illicit cigarettes”.

As a token of consideration, the panel has suggested a marginal increase in the size of pictorial warnings from the present 40 to 50 per cent.

At the same time, it has recommended that pictorial warning rules for beedi, chewing tobacco, zarda and khaini should be relaxed.

The health ministry notification seeks an increase in the size of health warning to 85 per cent of principal area of a pack for all tobacco products.

The panel is particularly soft on the beedi industry, which finds solid representation on the panel itself (in the form of beedi baron-turned-MP Shyama Charan Gupta, among others).

Every page of the 109-page report has distinct pro-tobacco tone.

Tobacco industry’s propagandist arguments have been repeated ad nauseam, but deposition of the health ministry and health advocates is summarily dismissed in a few paragraphs.

Of 17 ‘stakeholders’ called to depose before the committee, as many as 13 represented the tobacco industry.

Curiously, the All India Beedi Federation has been listed as an NGO.

It is surprising that while the finance ministry has gone tough on tobacco – in successive Budgets as well as in proposed GST structure which talks of a ‘sin tax’ on tobacco – members of Parliament are trying to create roadblocks and singing paean to tobacco industry

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