The Framework Convention Alliance for Tobacco Control

Is bigger better? There’s no doubt for tobacco warning labels

Health warnings labels in Urugay: 50% (old) and 80% (current)
An expert commentary on the global treaty, Framework Convention on Tobacco Control

By Jim Thrasher*

Increasingly, countries that have already implemented pictorial health warning labels (HWLs) that cover up to 50 percent of tobacco packages are promoting, adopting, and implementing more prominent HWLs1.

This includes Uruguay, where increasing the size of HWLs from 50 percent to 80 percent of the pack was used by Phillip Morris International as evidence that Uruguay had treated the company unfairly, citing a bilateral investment treaty (BIT) between Uruguay and Switzerland.

After six years of litigation, the World Bank’s International Centre for Settlement of Investment Disputes (ICSID) recently sided with Uruguay, concluding that adoption of tobacco control measures to improve public health trump PMI’s concerns about market fairness. What is the public health case for increasing the size of HWLs?

Various groups surveyed

Scientific evidence consistently indicates that larger HWLs work better than smaller ones. Studies have been conducted across diverse populations (e.g., adolescents and adults; non-smokers and smokers; smokers who do and do not want to quit; respondents from different countries and from the same country over time) using various protocols (e.g., ratings of single packages; direct comparison between packages; consumer perceptions before and after implementation of larger HWLs; focus group discussions).

The results provide convincing evidence that there is no clear threshold after which larger HWLs are no more effective than relatively smaller ones.

To address the tobacco epidemic, the international treaty, Framework Convention on Tobacco Control (FCTC), recommends numerous policies and strategies, including the adoption of prominent pictorial HWLs covering more than 50 percent of tobacco packs. This policy recognizes that adult consumers and youth are not aware of the full scope and severity of health risks from tobacco consumption.

Adolescents notice

According to general theories of communication, capturing attention is the critical first step towards effective communication. Substantial and consistent support has been found for the basic principle that larger HWLs are more effective in gaining attention than smaller HWLs. Perhaps more important is the evidence that larger HWLs attract greater attention among adolescents who do not consume tobacco.

Once attention is captured, the next objective for HWLs is to effectively communicate risk information. The most effective HWLs promote a true appreciation of the risks that someone will incur if they consume the product. The vast majority of experimental, observational and qualitative studies on this topic support the contention that larger HWLs are more effective in communicating risk.

Several experimental studies have been carried out amongst Canadians who, at the time the studies were conducted, had been exposed for a number of years to pictorial HWLs that covered 50 percent of packages. Furthermore, observational data from Uruguay that span implementation of a 50-percent pictorial HWL regulation to an 80-percent regulation showed that smokers more frequently processed HWL messages about risk.

The conclusions from these and other related studies: larger HWLs better communicate risks than smaller HWLs, including when HWLs that cover more than 50 percent are compared with those that cover 50 percent or less.

Better at discouraging smoking

Studies also have addressed the issue of whether larger HWLs are more effective in eventually discouraging smoking. Experiments that evaluated adolescents’ and adult smokers’ perceptions favoured the greater efficacy of larger HWLs, including when HWLs were made larger than 50 percent of the package.

Observational studies have consistently found more frequent thoughts about quitting and quit-related behaviours when larger HWLs are implemented. Moreover, when consumers have been asked how to make HWLs more effective, they inevitably recommend making them bigger.

All prior literature reviews of the available evidence, except those funded by the tobacco industry, have concluded that the scientific evidence shows that the largest HWLs are the most effective 2,3,4.

Countries increasing HWLs

The adoption of prominent, pictorial HWLs was relatively rapid, albeit somewhat uneven, around the world, and some evidence indicates that its adoption is slowing down5. However, increasingly countries such as Australia, Canada, Uruguay and India have been adopting pictorial HWLs that cover more surface area to enhance their impact, while also introducing new HWL content.

It is important to note that larger, pictorial HWLs not only provide more space for communication, but that they also reduce the amount of space available for the tobacco industry to include brand information on packs. While this is the goal of plain packaging, countries may also reach this end by adopting large pictorial HWLs.

*Associate professor of Health Promotion, Education, and Behavior at the Arnold School of Public Health, University of South Carolina and Visiting Professor and Researcher, National Institute of Public Health, Cuernavaca, Mexico

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