With the unveiling of nine graphic images that will adorn every cigarette pack sold in the U.S. starting in fall 2012, government officials and outside experts predict there will be an initial wave of smokers who seek help in quitting. But they caution that regulators will have to refresh — and possibly dial up — their message so that consumers don’t grow complacent about the omnipresent warnings.
The graphic labels released Tuesday are “an important and powerful tool” in the fight to reduce tobacco-related disease and death, said Food and Drug Administration Commissioner Margaret A. Hamburg. She said the new campaign could induce as many as 213,000 of the nation’s 46 million cigarette smokers to quit in the first year. The American Lung Assn. warned local quit lines to brace for a deluge of calls.
Hamburg and other officials also emphasized that the FDA would continue to study the effects the images have on the public, and would probably update them yearly in an effort to keep them and their message fresh in consumers’ minds. Outside experts said the government would have to vary the messages to avoid what psychologists call “wear out.”
The nine images chosen by the FDA — the first update to cigarette-package warnings in a quarter-century — are stark and often disturbing. Each is accompanied by simple text informing cigarette buyers of the known consequences of their habit. One of the nine appears to depict a cadaver after an autopsy and states simply, “Smoking can kill you.”
Another, set against the warning “Cigarettes are addictive,” shows a man blowing cigarette smoke out of a tracheostomy hole in his neck.
Other warnings make a clear appeal to smokers’ concerns about the effects on others, an approach that research has found highly effective in getting them to try quitting. In one, a photo of a distraught woman bears the warning, “Tobacco smoke causes fatal lung disease in nonsmokers.” In another, a toddler clutched to the chest of an adult gazes anxiously at a nearby swirl of smoke, accompanied by the message, “Tobacco smoke can harm your children.”
Only one of the images conveys hope and encouragement to the dwindling number of Americans who cling to their smoking habit despite growing social isolation and, in almost four of five smokers, a strong desire to quit. In it, a robust, 30-something man with a sharp-looking goatee and a determined stare pulls open his shirt to reveal a T-shirt that declares, “I Quit.” The text reads, “Quitting smoking now greatly reduces serious risks to your health.”
The initiative is the most dramatic such effort by the FDA since the 2009 Family Smoking Prevention and Tobacco Control Act gave the agency expanded regulatory powers over tobacco. It is also the first time in 25 years that the health warnings on the packaging of tobacco products has been updated beyond the bland statement, in small type, that the surgeon general of the United States has determined cigarette smoking to be harmful to human health.
The new warnings didn’t impress everyone Tuesday.
“They’re obnoxious,” said Long Beach resident Bob Kohl, a 60-year-old smoker of 43 years who was diagnosed two years ago with emphysema and has quit three times. “They are insulting. They are very specifically condescending, which irritates me. It’s nothing I haven’t seen before, and it’s going to be meaningless to the kids because their attitude is worse than mine.”
In requiring the graphic warnings, the U.S. joins about 40 other countries that require cigarette packaging to carry prominent — and often grim — warnings on the dangers of smoking. Canada and European countries pioneered the practice, and several developing countries, including Mauritius, Uruguay, Thailand, Malaysia and India, also requiregraphic anti-smoking messages.
Starting Sept. 22, 2012, the images and related text will cover the top half of all cigarette packages sold in the U.S., making them “new mini-billboards for prevention,” said Dr. Howard Koh, assistant secretary for health at the Department of Health and Human Services.
The warnings, added William Corr, deputy secretary of the department, “will forever change the look” of the 15 billion packs of cigarettes purchased by Americans annually. The mandated package coverings “tell the truth,” Corr said, contrasting them with messages crafted by the tobacco industry, which spends $12.5 billion annually to advertise its wares.
The images were culled from 36 candidates the FDA circulated for public comment starting last June. The agency ruled out some far more disturbing images, including an unsparing photograph of a bald lung cancer victim hollowed out by her disease.
But as the public grows inured to the effects of the images, the FDA might well turn to pictures it may have passed over as too grisly and discouraging, experts said. As it escalates the shock value of the images, the FDA must thread a careful path between simply sticking to the facts and presenting images and warnings in ways that are attention-grabbing enough to break through smokers’ resistance and discouragement, said Geoffrey Fong, lead researcher of the International Tobacco Control Policy Evaluation Project at the University of Waterloo in Canada
“It’s a really good start,” Fong said. “But we also need to recognize where people in the United States are right now, which is no exposure to these kinds of images.”
Fong, who has studied the effectiveness of Canada’s 2001 introduction of graphic warning labels, said that while they had a powerful effect on smokers’ intentions to quit in the first two to three years, their sway with consumers declined markedly — by 30% to 60% — between 2003 and 2009, when Canada stuck with the same warnings.
The messages “don’t have to be more intense, they could just be different,” Fong said. “With the harms of smoking, you have a lot to choose from; you’re not going to be running out of ideas.”
The views of activists and researchers influenced the FDA’s deliberations in other ways as well. During the months-long comment period, a wide range of experts urged the FDA to add a toll-free number to each image that would direct callers to help with quitting. The FDA acted on the recommendation, affixing the tagline “1-800-QUIT-NOW” to each image.
Several researchers emphasized that the inclusion of a quit-line number was crucial in prompting smokers moved by the warnings to act.
“Everything we know about frightening and scaring and persuading people is that you want to give them a place to go, or an action to take, to avert the consequences you’re warning them about,” said Joseph Cappella of the Center of Excellence in Cancer Communication Research at the University of Pennsylvania’s Annenberg School for Communication.
State, local and nonprofit smoking cessation groups should gear up for a major influx of callers as the warnings hit the streets, the American Lung Assn. urged.
“No smoker should hear a busy signal or be placed into voicemail when they are finally ready to make the lifesaving decision to quit smoking,” the association said in a statement Tuesday.
Los Angeles County’s director public of health, Jonathan E. Fielding, said he expected that the “visceral appeal” of the warnings would increase calls from would-be quitters to smoking-cessation lines, and also bolster local policy initiatives that would make it even harder for smokers to find places to light up. Among those initiatives is a proposal to ban smoking in multi-unit housing, a measure already adopted in South Pasadena and circulating in Los Angeles County.
In an interview Tuesday, the FDA’s Hamburg expressed hope that the campaign would energize anti-smoking efforts nationally. Federal officials say tobacco use claims 443,000 American lives a year and costs $200 billion in lost productivity and added healthcare costs.
They will have their work cut out for them. Nationally, 21% of American adults smoke — including 14.3% of adults in Los Angeles County — and among them are the most addicted and most discouraged. And though smoking rates have declined dramatically since their peak of near 40% in the 1960s, they have declined little in the last decade.
Meanwhile, about 4,000 teens a day try their first cigarettes, and 1 in 4 will take up the habit.