Review of the science base to support the development of

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A review of the science base to support

the development of

health warnings for tobacco packages

This report has been prepared for European Commission, Directorate General for Health and Consumers.

The views expressed in this document are the sole responsibility of its authors and do not necessarily reflect the views of the European Commission.

Sambrook Research International

30 Station Road

Newport Ref : R 306

Shropshire 18th May 2009

TF10 7EN Tel 01952 551188

England Fax 01952 551163

E-mail :



Main findings and overall conclusions 1

Recommendations 5


Background, objectives and overall research requirements 6


How consumers look at packaging / labels 8

Effectiveness of warning labels generally 9


Background information on tobacco warning labelling 10

Review of scientific knowledge on general tobacco warning labelling 11

Evaluation of the effectiveness of TEXT ONLY tobacco health warnings 15

Evaluation of the effectiveness of specific pictorial tobacco health warnings 22


Effectiveness of graphic warnings versus text only messages 45

Analysis of warning effectiveness 47

Key design parameters to create effective warning labels 52


Overview of the main illnesses related to smoking and second-hand smoke 55

Review of the scientific evidence of the health effects of tobacco 57

Health and other benefits from smoking cessation 87


Proposed new warning messages 88


Main findings and overall conclusions 116

Recommendations 118


Appendix 1 – References regarding effectiveness of health warnings 120

Appendix 2 – Evidence on effectiveness of tobacco health warning labels in general 125

Appendix 3 – Evidence of effectiveness of pictorial warnings versus text only 135

Appendix 4 - Overview of tobacco warning messages used with pictorial warnings 139

Appendix 5 -Information on health labelling in non-tobacco sectors 143

Appendix 6 – The 42 pictorials used in the EU 149

Appendix 7 – Plain packaging and its likely impact 154

Appendix 8 – References regarding the health effects of smoking 158

Appendix 9 – List of people contacted for feedback 163


Main findings and overall conclusions

  • The purpose of this report is to provide the European Commission with a review of the scientific knowledge on health and tobacco labelling, an evaluation of the impact of the existing textual and pictorial warnings and a proposal for warning messages based on a state-of-the-art knowledge on tobacco-related harm.

Scientific knowledge on health labelling generally

  • Consumers usually examine packaging in a systematic way, looking at the elements in order of visual dominance. Warning labels are more effective if they systematically address key behaviour processes – attention, reading, comprehension, recall, judgement, behaviour compliance.

Scientific knowledge on the effect / impact of tobacco warning labels on consumers

  • There is clear evidence that tobacco package health warnings increase consumers’ knowledge about the health consequences of tobacco use and contribute to changing consumer’s attitudes towards tobacco use as well as changing consumers’ behaviour. They are also a critical element of an effective tobacco control policy.

    • Warnings have a high impact in educating consumers of the health risks of tobacco use

    • Warnings have a medium impact in changing smokers attitudes (in particular thinking about quitting and smoking in the presence of non-smokers)

    • Warnings have a medium impact in changing smokers’ behaviour (including smoking less, smoking less around others, using quit lines, attempting to quit and quitting)

Principles of effective tobacco warning labels

  • Combined pictorial + text warnings are significantly more effective than text only warnings, especially educating the public of the health risks and changing consumer behaviour. They are also more effective than text only in minimising ‘wear out’ over time.

  • Fear inducing warnings (using strong ‘shocking’ images related to health risks) and strong emotion inducing warnings (especially involving children and unborn babies) are the most effective way to educate consumers on the health risks of tobacco use and to achieve changes in attitudes and behaviour. These warnings’ effectiveness is enhanced if they are used in conjunction with advice on where to obtain help, e.g. a quit line.

  • Many warning messages have universal appeal. However, developing messages that target specific consumer groups is also of value. Certain messages clearly have higher resonance with one target group and less resonance with others.

  • The report provides detailed recommendations regarding the key design parameters and their optimum specification. The key parameters of importance are as follows:

    • Size - optimally 100% and at least 50% (excluding borders) of the total facial area.

    • Colour pictures used in all warnings together with short easily understood text messages that are clearly linked to the graphical image.

    • Location – pictorial + text warnings should preferably be used on both sides, and as a minimum requirement on the front of packs.

    • The warning should be hung from the top of the pack to maximise visibility. For packs that have a front opening mechanism, front warning should be hung from the ‘cut line’ (to avoid the warning being severed when the package is opened).

    • Toll free quit line number on every pack – ideally this should be separate from the warning to avoid reducing the size (and impact) of the pictorial within the warning.

    • Plain packaging – using an unattractive standardised colour with the removal of logos / brand images and associated colours, with brand names in a standardised colour (black) and font size.

Inserts that contain information on the immediate health benefits of quitting as well as advice on how to quit and details of the quit line number could also be considered.

  • Warnings should be optimally split into two sets, each set rotated ideally every 12 months (maximum every 18 months) to minimise wear out effects.

  • The optimum renewal period for the warning messages is broadly seen as every 2-5 years. If a rotation period of 12 months is adopted, then the warnings / images should be reviewed after 4 years (allowing each message to be used at least twice).

Scientific evidence of the health effects of tobacco use

  • The key diseases associated with smoking for which the research shows there is strong evidence of a causal link are given below.


Cancer diseases

Lung cancer (bronchus, trachea)

Head / neck cancer (mouth, larynx, pharynx, oesophagus, nasal/sinus)

Kidney / ureter cancer

Pancreatic cancer

Stomach cancer

Bladder cancer

Cervical cancer

Leukaemia (especially acute myeloid leukaemia)

Non- cancerous respiratory diseases

Chronic obstructive pulmonary disease COPD (emphysema / chronic bronchitis)

Other respiratory effects (asthma, coughing, phlegm, wheezing and dyspnoea)


Cardiovascular diseases

Heart attack / coronary heart disease / aortic aneurysm



Atherosclerotic / peripheral vascular disease

Reproductive and pregnancy related diseases

Male / female fertility

Reduced foetal growth / low birth weight baby

Miscarriage / spontaneous abortion

Perinatal death

Increased risk for sudden infant death syndrome

Premature birth

Premature rupture of the membrane

Increased risk of placenta previa

Increased risk of placental abruption

Impotence / erectile dysfunction

Other diseases

Blindness / age related macular degeneration / cataracts; Ageing of the skin; Osteoporosis / hip fracture; Gastric ulcer; Dental disease;

Other diseases that are associated with smoking where evidence is suggestive but not sufficient to infer a causal relationship include; anal cancer, vagina/ vulva cancer, ovarian cancer, penis cancer, prostate cancer, colorectal (bowel) cancer, liver cancer, breast cancer, chronic rhinitis, multiple sclerosis, goitre, diabetes and crohn’s disease asthma, breast cancer, rheumatoid arthritis.


Diseases caused in adults

Coronary heart disease; Lung cancer; Reproductive effects in women / low birth weight; Respiratory symptoms (nasal irritation)

Diseases caused in children

Middle ear disease; Sudden infant death syndrome (SIDS); Respiratory diseases;

Other diseases that are associated with passive smoking where evidence is suggestive but not sufficient to infer a causal relationship include: Adults - nasal sinus cancer, stroke, COPD / asthma, AMD, atherosclerosis/ peripheral vascular disease and pre-term delivery. Children - brain tumours, lymphoma, asthma, leukaemia, meningitis, cognitive development and behaviour problems.
Proposed new warning messages

  • 24 new warning messages have been developed, based on analysis of the scientific evidence, discussions during in-depth interviews and stakeholder feedback. Some have universal appeal others have additional resonance with specific age groups / gender.

Type of message

Proposed warning message

Primary target groups






Health appeal messages

Messages related to cancer diseases

  1. Smoking causes 9 out of 10 lung cancers

  1. Smoking causes mouth and throat cancer

  1. Smoking doubles the risk of cervical cancer

  1. Smoking causes leukaemia

Messages related to non cancerous respiratory diseases

  1. Smoking destroys your lungs

  1. Smoking causes suffocating breathlessness for life

Messages related to cardiovascular diseases

  1. Smoking causes heart attacks

  1. Smoking causes strokes and severe disability

  1. Smoking causes leg amputations

Messages on other illnesses caused by smoking

  1. Smoking causes blindness

  1. Smoking causes rotten teeth and gums

Social appeal messages

  1. Smoking can kill your unborn child

  1. Your smoke harms your children, family and friends

  1. If you smoke your children will smoke

Cessation appeal messages

  1. Quit now – stay alive for your children

  1. Stop smoking now - your health benefits immediately

  1. Get professional help – it makes it easier to quit

Other messages

  1. Smoking makes it harder to have children

  1. Smoking reduces your sexual performance

  1. Smoking is severely addictive - don’t start

  1. Smoking reduces your sports performance

  1. Smokers die younger

  1. Smoking causes wrinkles

  1. Tobacco smoke contains highly toxic chemicals

Note. The target groups are indicated marked with A to E. A = teenage male, B = teenage female, C = young adult men (aged 20-40), D = young adult females (aged 20-40), E = other older adults

Summary - overall conclusions
The research has identified over 30 health risks for which there is a proven causal link and supported by evidence at two major International organisations – the US Surgeon General and IARC. Some of these risks are already well known, others will be new to consumers. There is strong, conclusive evidence that pictorial warnings are significantly more effective than text only warnings. There is clear evidence that they have a strong impact in educating consumers about the health risks of tobacco use and stimulating discussion with family members and friends. They also have a positive impact in changing smokers’ attitudes and behaviour (in particular not smoking around others, smoking less and trying to quit). Fear inducing images (related to health risks) and strong emotion inducing images (especially children and unborn babies) is the most effective way to stimulate consumers to notice and read the associated text warning messages, which is enhanced if they are used in conjunction with advice on where to obtain help, e.g. a quit line, and plain packaging.
24 new health warnings are suggested, which include health risk appeal warnings, social appeal, cessation appeal and other messages. Many have universal resonance, some have particularly high resonance with specific age groups or gender.

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