As the second leading cause of death in the world, cigarette smoking is a preventable behavior. Most countries require warnings about health risks on every package, but the effectiveness of these warnings depends upon the design and the "freshness" of the messages. In a multi-country study published in the March 2007 issue of the American Journal of Preventive Medicine, researchers found that more prominent text messages were more effective and graphic pictures even more so in affecting smokers' behaviors. Recent changes in health warnings were also associated with increased effectiveness, while health warnings on US packages, which were last updated in 1984, were associated with the least effectiveness.

The authors analyzed data from four waves of surveys taken during 2002-2005 of adult smokers in Canada, the United States, the United Kingdom and Australia. Almost 15,000 smokers were surveyed on their awareness of the messages, any changes in understanding of the risk of smoking, their intention or motivation to quit and any behavioral changes they had noticed in themselves.

The International Tobacco Control (ITC) Four Country Survey collected the responses from the same smokers, approximately 2 months before new UK warnings were implemented, and then at 6, 18 and 32 months after implementation. Warnings on the packages ranged from graphic pictures covering half the package in Canada to small text warnings on the side of packages in the US. The first international treaty devoted to public health, the Framework Convention on Tobacco Control (FCTC), has mandated "large, clear, visible and legible" warnings that cover at least 30 per cent of the surface. Canada currently meets this guideline, although most countries fall short. Thus, the current study evaluated warnings that were: (1) well below the minimum FCTC standard (US and UK at baseline); (2) slightly below the FCTC minimum (Australian warnings), (3) enhanced to the FCTC standard (UK at follow-up), and (4) at the recommended FCTC standard (Canada).

Writing in the article, David Hammond, PhD, states, "This study suggests that more prominent health warnings are associated with greater levels of awareness and perceived effectiveness among smokers. In particular, the findings provide strong support for the effectiveness of new health warnings implemented on UK packages that were enhanced to meet the minimum international standards...UK smokers were also more likely to report that the new warnings had led them to think about quitting, to think about the health risks of smoking, and had deterred them from having a cigarette compared to Australian and US smokers. Although the findings provide strong support for the effectiveness of prominent text warnings that meet the minimum international standards, the findings also suggest that larger pictorial warnings may have an even greater impact: data collected two and a half years after the implementation of the Canadian pictorial warnings and two and a half years after the implementation of the new UK warnings indicate that the Canadian warnings had impact levels at or above the UK warnings for each of the measures examined in the survey."

The article is "Text and Graphic Warnings on Cigarette Packages: Findings from the ITC Four Country Survey" by David Hammond, PhD (Department of Health Studies, University of Waterloo, Waterloo, Ontario), Geoffrey T. Fong, PhD (Department of Psychology, University of Waterloo, Waterloo, Ontario), Ron Borland, PhD (The Cancer Council Victoria, Melbourne, Australia), K. Michael Cummings, PhD (Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY USA), Ann McNeill, PhD (Division of Epidemiology & Public Health, University College London, London, UK) and Pete Driezen, MSc (Department of Health Studies, University of Waterloo, Waterloo, Ontario). It appears in the American Journal of Preventive Medicine, Volume 32, Issue 3 (March 2007) published by Elsevier.

Note: This article has been adapted from a news release issued by Elsevier Health Sciences.