It’s easy to guess what would happen if a pharmaceutical company asked the Food and Drug Administration to approve a new product with the following characteristics: no proven health benefits. Major known side effects: greatly increased risk of emphysema, heart attacks, stroke and cancer, including lung, cervical, mouth, stomach and bladder. The product also lowers bone density in older women and causes higher rates of serious health problems among newborns. It significantly harms the health even of those who merely spend time near the drug while it’s in use. And it’s addictive.
If cigarettes were a new invention, they’d never pass muster with even the most lax of regulatory agencies. Unhappily for our collective health, not only does tobacco’s legacy date back thousands of years, but it is inextricably tied to the birth of the United States. None other than John Rolfe, best known as Pocahontas’ husband, is credited with the first commercial cultivation of tobacco in Jamestown, in 1612.
Four hundred years later, we’ve learned a thing or two about tobacco, especially in its inhaled form. Now we wrestle with how to act on that information. Cigarettes are a terrible health scourge, but this is also a country that respects the right of adults, in most cases, to ruin their own health as long as they are not endangering others. So driving drunk is forbidden, as is smoking in many indoor public spaces, but cigarettes themselves remain legal.
Yet as a society, we don’t want to sit idly by and watch tobacco take its toll. So we tried public service messages to counter the lure of cigarette advertising. Then we banned TV commercials and placed small warnings from the surgeon general on cigarette packs. We raised excise taxes and restricted the settings where smoking is legal.
It worked. Smoking rates are half what they were 40 years ago, with only one in five Americans lighting up. (In California, which has led the nation in anti-smoking laws and public service messages, the rate is lower than 13%.)
For the past six years, though, progress against cigarettes has stalled, which led to congressional action last year in the form of a law empowering the FDA to regulate tobacco and requiring large, visually arresting anti-smoking warnings on every cigarette pack. The recently unveiled images, which will cover half of the front and back of each pack, show tar-blackened lungs and toe-tagged corpses, along with many tamer pictures. The depictions must also be shown in cigarette advertisements, and must take up a fifth of the ad’s space.
In the past decade, 38 countries started requiring cigarette packs to carry images designed to discourage the habit. Early research offers encouraging signs that they work, and do so without requiring a major investment of taxpayer money. Short of banning cigarettes altogether, it will take this sort of bold action to prod the nation into further reducing tobacco use. If anything, the FDA’s new warning labels err on the side of being too tepid.
We don’t say that lightly. The images will in effect force tobacco companies to advertise against themselves on the packages of their own products. The possible analogies are endless: Should wineries be required to include color photos of cirrhotic livers on their labels, or should KFC buckets of chicken have to feature a cross-section of the fat deposits on an obese individual? Concerns about a slippery slope are valid — it would be distasteful and ultimately unhelpful to litter the landscape with repulsive pictorial warnings — but those concerns shouldn’t stop the FDA from taking this potentially life-saving course of action.
That’s because when it comes to health-destroying products, cigarettes are in a class of their own. They have no real benefits and are addictive as well. Though many people might treat themselves to an occasional plate of fries or a bottle of beer, rare is the person who enjoys a cigarette every couple of weeks. Many smokers were lured into addiction by an industry that purposely withheld information about its product’s horrific effects on health. Smoking remains the No. 1 cause of preventable death in the United States.
In 2001, Canada became the first country to adopt the big, colorful, graphic warnings. Smoking rates among Canadian youth ages 15 to 19 have dropped from 26% to 15%. Adult rates dropped less dramatically. But it’s impossible to know how much of the reduction was prompted by the warning labels, because several other anti-smoking initiatives started in the country around the same time.
Still, the results from surveys in 15 countries offer persuasive evidence of the labels’ effectiveness. Smokers noticed and remembered the images better than text warnings and said the new labels had given them important health information. Teenagers were more likely to say the graphic warnings had discouraged them from smoking altogether, and adults were more likely to have at least tried to quit or to have refrained from taking the next cigarette they had planned on smoking.
As helpful as it is to adopt more prominent warnings, equally important is making sure they have the maximum impact. The FDA is considering 36 possible images, and will narrow those to nine. But David Hammond, an assistant professor at the University of Waterloo in Canada and one of the leading researchers on the topic, says many of the images are too tame to grab consumer attention. One of the most effective Canadian images shows a grinning, cancer-riddled mouth; opening the package also opens the mouth, the teeth parting to reveal the neatly packaged cigarettes. There’s a less repulsive version of the cancerous mouth among the FDA’s contenders, along with one of a smoker exhaling through a hole in his throat. But many of the FDA’s images are more symbolic than graphic; it should use the most dramatic ones.
Research shows that the warning labels work better when they’re coupled with an increase in smoking-cessation programs, and when they include a phone number or website where smokers can get quick information on how to quit. The change in cigarette labeling is welcome, but the FDA could do more. If the idea is to startle people into quitting, this is no time for timidity.