When what you see is what you get

MANILA, Philippines – I clearly recall the first time I glanced at the image of a diseased mouth on a cigarette pack. The photo showed rotting black teeth and bloodied ulcers on the gums, lips and tongue of a young person. I cringed for a moment but let the feeling subside.

I have been around chronic smokers all my life. Most of them seem immune to reason or to any medical information about the bad effects of tobacco. The usual retort is, “I know, I know. It’s bad for my health. But what can I do?” End of conversation.

Recent research, however, shows that smokers do not know exactly what tobacco use does to their bodies. Smoking is primarily associated with lung cancer, but, in fact, tobacco kills far more people through heart disease than through cancer.

In China, for example, a February 2009 survey showed that 37 percent of smokers knew that smoking caused lung disease, but only 17 percent knew that it caused stroke. In a 1996 national survey in South Africa, it was reported that 87 percent of respondents acknowledged the harmful effects of smoking, but only 58 percent were aware that it was associated with cancer and only 36 percent associated it with heart disease. Studies in India show that fewer than half of school and college students in Gujarat (a tobacco-growing state) were aware that chewing betel nut with tobacco is associated with oral cancer.

There is a gap between what the public health community knows about tobacco and what smokers and the general public know. Bridging that gap has always been a challenge.

For this year’s World No Tobacco Day, tomorrow, May 31, WHO is focusing on the issue of pictorial health warnings on cigarette packs. Research on the use of these warnings points to a “teaching moment” on the product itself. When what you see on the pictorial health warning is what you may get, it is highly likely that you will think again about pulling out that next stick.

In Brazil, for example, more than half of smokers changed their opinion on health consequences after seeing pictorial warnings, and 67 percent said the warnings made them want to quit. In Singapore, 71 percent of smokers said that they knew more about the health effects of smoking after the introduction of warnings, and 28 percent said they consumed fewer cigarettes because of them. In Canada, 27 percent smoked less inside their homes as a result of the warnings.

Recently, in Brazil and New Zealand, pictorial warnings have been accompanied by quit hotline numbers. In Brazil, in the six months following the implementation of pictorial warnings with a quit hotline reference, calls to the line increased nine-fold.

In New Zealand, the number of callers to quit hotlines increased by 14 percent in the six months following the introduction of pictorial warnings. More callers said they had got their information about hotlines from packs with pictorial warnings rather than television ads.

Research also shows that the more shocking and the more unpleasant the photographs, the more likely they will result in behavioral change. Studies also show that avoidance of these photos by smokers does not decrease their effectiveness in getting them to quit.

Legislation requiring tobacco companies to use pictorial warnings has been opposed by the tobacco industry on the grounds that there is no evidence that these kinds of warnings work or that these warnings violate freedom of speech and trademark rights. But, in fact, the evidence that pictorial warnings work is robust. The tobacco industry lost its only serious court challenge against pictorial warnings before the Supreme Court of Canada in 2007.

Litigation may still be a possibility in some countries, and there also are lessons learnt from countries like Thailand, for example, on how to handle threats of litigation. In Thailand, the industry argued that pack warnings violated Thai Constitution Article 29 on individual rights and freedom to speak, write, print and advertise. Through the media, the Ministry of Public Health insisted that the state could limit individual rights or freedom to protect national security and the health of consumers and citizens.

The Secretary General for Human Rights in Thailand publicly supported the position of the Ministry of Public Health. The Director of the Thai Health Promotion Institute publicly challenged the industry to sue the government. Through a series of public announcements from different authorities, the government called the industry’s bluff, and the tobacco control community won the public debate and successfully got the people themselves on their side.

To fulfill obligations to the WHO Framework Convention on Tobacco Control, countries in the WHO Western Pacific Region have three years from entry into force of the Convention to implement warnings on tobacco products. Pictorial warnings cost virtually nothing -other than costs associated with the implementation of government policy. Moreover, shocking and unpleasant pictorial warnings remain in the mind long after that first glance at a pack. It’s time for governments to use shock tactics.