It's Great American Smokeout Day—Without the Graphic Images

The courts won't allow pictorial warning labels on cigarettes, but a new study shows they work

The United States is one of the few countries that prohibit the use of graphic health warning labels on cigarette packages. (Photo: Getty Images)

Shari Roan is an award-winning health writer based in Southern California.

Thousands of Americans will try to stop smoking today on the annual Great American Smokeout day. Perhaps more of them might succeed at long-term cessation if the United States permitted graphic warning labels on cigarette packages.

According to a new study, graphic warnings—such as pictures of a someone dying of lung cancer or using a respirator to breathe—have more impact in driving home the dangers of smoking compared to the text-only messages that appear on cigarettes now.

By now, graphic warning labels were supposed to be in circulation. Since 1985, the United States has had four text-only messages that appear on cigarette packages. But in 2009, the Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration regulatory authority over tobacco products, including health warning label content.

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Graphic warnings were vetted by FDA, approved and were set to begin appearing in September. But a U.S. Court of Appeals ruled in August that the decision violated First Amendment rights. The court also said there wasn't enough evidence that the images would be effective to reduce smoking.

More than 40 countries have added pictorial health warnings on cigarette packages. Under World Health Organization guidelines, health warning labels should cover 50 percent of the front and back of each cigarette package and include one of nine combinations of text and images.

"There's been a lot of research conducted in other countries that have implemented warning policies of this type where pictures and text are included in the warnings," Dr. James Thrasher, the author of the new study, told Take Part. Thrasher is an associate professor in health promotion, education and behavior in the  Arnold School of Public Health, University of South Carolina. "We've consistently seen that that kind of warning works better than warnings that include only text."

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The country's approach to warning labels has emerged as a key issue in addressing the last, large bastion of smokers in the United States. Studies show smoking is concentrated among lower socioeconomic groups. This is a population of people in which health literacy—the ability to read and understand educational health information—is also low. Previous studies suggest that people with low health literacy don't always understand text-only health warning labels on cigarette packages.

The new study of 1,000 adult smokers, published in the American Journal of Preventive Medicine, examined the impact of graphic warning labels compared to traditional text warning labels, such as "smoking causes cancer." One group of study participants, all smokers, rated four traditional text health warning labels that are already on cigarette packs. Another group of smokers rated nine different pictorial labels. Each of these messages combined text with an image depicting diseased organs, human suffering or an abstract symbol, such as a tombstone.

The smokers rated the graphic images as more credible, personally relevant and effective. Thrasher and his colleagues also found smokers with low-health literacy rated pictorial labels as more credible than text-only warnings, whereas no difference in credibility was found among smokers with high health literacy. However, all participants rated the graphic health warning labels as the most effective and most likely to influence them.

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"In the United States, smoking is increasingly concentrated among the more disadvantaged groups, groups with lower levels of education," Thrasher says. "There is a particular interest in thinking about how we can develop interventions that can better reach this group. This kind of policy with strong, graphic pictorial warnings appears to work best in that population."

The paper notes that the tobacco industry has argued that the FDA's proposed warning label images are "not real and involves emotional appeals instead of the simple transmission of risk information."

But he says the study showed people found those images very real and relevant.

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The tobacco industry "suggests that these warnings are emotional and that the FDA should be charged with communicating the risks of smoking sort of independent of emotional messages," Thrasher says.

But, he adds, "We're emotional human beings that respond to emotional messaging. The more graphic warnings—the warnings that really produce an emotional response—are the ones that work best. These are ones that put a human face on the suffering produced by smoking."

It's not yet clear how the FDA plans to proceed since the August ruling. It could appeal the decision to the U.S. Supreme Court.

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Thrasher says he expects public health leaders to continue to make a strong case for graphic warning labels.

"The key right now, from the public health perspective, is we need to get these on packages," he says. "In some sense, we're mobilizing and conducting studies like this with the intent of informing some of the legal decisions facing the courts."

Question: Do you think the courts should allow the FDA to move forward with graphic-image health warning labels on cigarettes? Tell us what you think in the comments.

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