tag:theconversation.com,2011:/us/topics/health-warning-26867/articleshealth warning – The Conversation2022-12-01T06:34:23Ztag:theconversation.com,2011:article/1957102022-12-01T06:34:23Z2022-12-01T06:34:23ZBanning menthol cigarettes and more health warnings are only the start. Australia could look to NZ for how to do tobacco control<figure><img src="https://images.theconversation.com/files/498360/original/file-20221130-12-akaqcq.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C1914%2C1279&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/7USMFYqt1NI">Pawel Czerwinski/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>This week’s <a href="https://www.abc.net.au/news/2022-11-30/government-to-ban-menthol-cigarettes-ugly-colours/101715174">announcement</a> of a raft of new tobacco control measures – including banning menthol products and proposing health warnings on individual cigarettes – are important and welcome.</p>
<p>We applaud Australian Health Minister Mark Butler’s <a href="https://www.croakey.org/wp-content/uploads/2022/12/ButlerSpeechTobacco.pdf">aim</a> to re-establish Australia as a global leader in tobacco control alongside fellow OECD nations, such as New Zealand and Canada.</p>
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<p>His announcement comes <a href="https://theconversation.com/australias-decisive-win-on-plain-packaging-paves-way-for-other-countries-to-follow-suit-140553">a decade after</a> Australia implemented world-leading laws that required all tobacco products to be sold in plain packs.</p>
<p>But there is still scope for more comprehensive action to reduce the burden smoking imposes on Australia and particularly on Australia’s Indigenous peoples.</p>
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Read more:
<a href="https://theconversation.com/we-can-cut-indigenous-smoking-and-save-lives-heres-how-42119">We can cut Indigenous smoking and save lives – here's how</a>
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<h2>We can look to New Zealand</h2>
<p>Aotearoa-New Zealand offers a useful comparison. The NZ parliament aims to pass legislation in mid-December that takes a different approach to the measures Butler outlined this week. </p>
<p>The <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-aotearoa-2025-action-plan">Aotearoa package</a> of measures were developed in close consultation with Māori leaders. These include making cigarettes non-addictive, greatly reducing the number of tobacco retailers, and creating a smoke-free generation. </p>
<p>These policies focus on fundamental drivers of smoking. The measures will also affect everyone in the same way, thus have great potential to reduce pervasive inequities in smoking rates.</p>
<p>Let’s see how Australia’s plans compare with policy reforms under way in New Zealand and Canada.</p>
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Read more:
<a href="https://theconversation.com/forget-tobacco-industry-arguments-about-choice-heres-what-young-people-think-about-nzs-smokefree-generation-policy-193529">Forget tobacco industry arguments about choice. Here's what young people think about NZ's smokefree generation policy</a>
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<h2>New health warnings</h2>
<p>Graphic images on packets of cigarettes were introduced in Australia <a href="https://www.health.gov.au/sites/default/files/evaluation-of-effectiveness-of-graphic-health-warnings-on-tobacco-product-packaging.pdf">16 years ago</a>, and these warnings have encouraged quitting. But they have lost their initial impact. </p>
<p>New and more varied warnings <a href="https://tobaccocontrol.bmj.com/content/28/e1/e71">will refresh</a> this existing policy as will introducing pack inserts providing “how to quit” information, which have been used in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542677/">Canada since 2012</a>. </p>
<p>In 2023, Canada is set to become the first country to require health warnings to be printed directly on the <a href="https://blogs.bmj.com/tc/2022/07/08/canada-publishes-proposed-regulations-to-require-a-health-warning-directly-on-every-cigarette/">cigarette stick</a>.</p>
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<p>Butler proposes adopting this measure for Australia, but with the addition of making the cigarette paper an <a href="https://tobaccocontrol.bmj.com/content/25/6/699.long">unattractive colour</a>, such as slimy green or faecal yellow-brown. </p>
<p>Like plain packaging, this measure will reduce the appeal of smoking and present smoking as unambiguously harmful and unattractive.</p>
<h2>Tightening up marketing</h2>
<p>Standardising pack size, filters, and banning terms such as “light” and “organic” in brand names will further limit misleading tobacco marketing.</p>
<p>Likewise, measures that eliminate gimmicks – such as flavoured “<a href="https://tobaccocontrol.bmj.com/content/25/3/275">crushballs</a>” inserted in filters that release a burst of flavour when crushed, or packs that include “bonus” cigarettes to offer a better deal – will further limit how tobacco companies promote their products.</p>
<p>Banning some flavouring additives, <a href="https://theconversation.com/the-us-fda-has-moved-to-ban-menthol-cigarettes-australia-should-do-that-and-more-182435">particularly menthol</a>, will reduce the appeal of smoking for some consumers. </p>
<p>When Canada banned menthol cigarettes federally in 2017, this measure <a href="https://tobaccocontrol.bmj.com/content/early/2022/04/27/tobaccocontrol-2021-057227.long">increased quitting</a> among people who smoked menthol cigarettes.</p>
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Read more:
<a href="https://theconversation.com/the-us-fda-has-moved-to-ban-menthol-cigarettes-australia-should-do-that-and-more-182435">The US FDA has moved to ban menthol cigarettes. Australia should do that and more</a>
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<h2>More transparency</h2>
<p>Tobacco companies will need to disclose tobacco sales volumes and pricing, as required in <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/tobacco-returns">Aotearoa-New Zealand</a>. </p>
<p>Companies will also need to disclose their advertising, promotion and sponsorship activities, as well as product ingredients and emissions. </p>
<p>These moves all reveal important <a href="https://tobaccocontrol.bmj.com/content/early/2022/08/25/tc-2021-057232.info">tobacco company activities</a> that undermine public health efforts. </p>
<p>They will also provide key information about what is in tobacco products, as required by the World Health Organization’s <a href="https://untobaccocontrol.org/impldb/article-10/">Framework Convention on Tobacco Control</a>.</p>
<h2>Vaping ads to be banned</h2>
<p>The final measure will apply tobacco advertising bans to vaping products. This policy will reduce inappropriate promotion of these products, including to young people. </p>
<p>This measure is in addition to, and separate from, the <a href="https://www.tga.gov.au/news/media-releases/tga-consults-potential-nicotine-vaping-product-regulatory-reforms">current review</a> of Australia’s regulation of nicotine vaping products. Addressing the rising problem of vaping among <a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">young people</a> is a key concern and efforts to reduce youth use are urgently needed.</p>
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Read more:
<a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">We asked over 700 teens where they bought their vapes. Here's what they said</a>
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<h2>There’s more to do</h2>
<p>These advances in Australian tobacco control policy align with measures implemented a decade ago in Canada or that are soon to start. We welcome such measures that make smoking less appealing and encourage quitting. </p>
<p>However, bigger jumps are required if Australia is to lead on eradicating the harms smoking causes. These initial measures announced also do not have a clear equity focus, such as the measures being implemented in Aotearoa-New Zealand. These have a bolder ambition of rapidly reducing smoking among both Māori and non-Māori peoples to less than <a href="https://www.smokefree.org.nz/smokefree-in-action/smokefree-aotearoa-2025">5% by 2025</a>.</p>
<p>Aotearoa-New Zealand’s proposed law will fundamentally change tobacco products by reducing the nicotine content to <a href="https://doi.org/10.1016/j.drugpo.2021.103436">non-addictive levels</a>. The law also dramatically reduces tobacco availability by decreasing the number of tobacco retailers by at least 90%, and will make it illegal to sell tobacco to anyone born after December 31 2008. </p>
<p><a href="https://theconversation.com/new-zealands-tobacco-endgame-law-will-be-a-world-first-for-health-heres-what-the-modelling-shows-us-187075">Modelling</a> indicates that Aotearoa-New Zealand’s package of measures are likely to achieve their goal of rapidly phasing out tobacco smoking.</p>
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Read more:
<a href="https://theconversation.com/new-zealands-tobacco-endgame-law-will-be-a-world-first-for-health-heres-what-the-modelling-shows-us-187075">New Zealand’s ‘tobacco endgame’ law will be a world first for health – here’s what the modelling shows us</a>
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<p>These measures go far beyond those Butler proposes for Australia. In particular, removing the product’s addictiveness and reducing availability means casual experimentation among young people will not lead to addiction, and quitting will become much easier for people who currently smoke.</p>
<p>The package of measures announced this week will continue declines in smoking following the “tried and tested” strategy of incrementally ratcheting up restrictions on tobacco products. </p>
<p>In contrast, the Aotearoa approach is a “Tobacco Moonshot” that aims to finish the job of ending the tobacco smoking epidemic in Aotearoa-New Zealand.</p>
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<p><em>The authors would like to acknowledge Tony Blakely, University of Melbourne, and Andrew Waa, University of Otago, for helpful comments and suggestions.</em></p><img src="https://counter.theconversation.com/content/195710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Coral Gartner receives funding from National Health and Medical Research Council and Australian Research Council. She is an editor for Tobacco Control, A BMJ journal.</span></em></p><p class="fine-print"><em><span>Janet Hoek receives funding from the Health Research Council of New Zealand and the NZ Cancer Society. She has also received funding from the Royal Society Marsden Fund. She is a member of the Health Coalition Aotearoa's Smokefree Expert Advisory Group and sits on several other advisory groups whose work supports the NZ Aotearoa Government's goal of realising a smokefree nation by 2025. </span></em></p><p class="fine-print"><em><span>Richard Edwards receives funding from the Health Research Council of New Zealand, the NZ Cancer Society, and from the National Institute of Health (USA). He has also received funding from the Royal Society Marsden Fund. He is a member of the Health Coalition Aotearoa's Smokefree Expert Advisory Group and sits on several other advisory groups whose work supports the NZ Aotearoa Government's goal of realising a smokefree nation by 2025.</span></em></p>Australia’s approach is welcome but doesn’t go far enough. New Zealand’s plans are much bolder. Here’s how they compare.Coral Gartner, Director, NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, The University of QueenslandJanet Hoek, Professor of Public Health, University of OtagoRichard Edwards, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168452019-05-20T13:45:01Z2019-05-20T13:45:01ZHow Ghana is using graphic pictures to cut tobacco use<figure><img src="https://images.theconversation.com/files/275137/original/file-20190517-69182-1eiq2sy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smoking is a threat to public health.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Ghana recently joined only a handful of countries in Africa to <a href="http://www.ghananewsagency.org/health/ghana-introduces-pictorial-health-warnings-on-cigarette-packs-139231">introduce</a> the use of pictures in health warnings on tobacco products. The other countries <a href="https://www.atim.co.za/2016/12/better-graphic-warnings-on-smoke-packs-but-africa-is-still-lagging-behind/">include</a> Burkina Faso, Cameroon, Chad, Djibouti, Egypt, Kenya, Madagascar, Mauritius, Namibia, Senegal and Seychelles.</p>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458743/">shows</a> that large, picture-based or pictorial health warning labels on tobacco packages are an effective strategy to reduce tobacco use. Several <a href="https://academic.oup.com/ntr/article/15/3/708/1091051">studies</a> have shown that labels are effective if they communicate the health risks of tobacco use and increase knowledge. </p>
<p>A combination of these factors can influence future decisions about smoking. Additionally, large and pictorial health warning labels can <a href="https://tobaccocontrol.bmj.com/content/25/3/341">encourage</a> smokers to quit, discourage non-smokers from starting and keep ex-smokers from starting again.</p>
<p>Estimates of tobacco use in Ghana are <a href="https://www.who.int/tobacco/publications/surveillance/reportontrendstobaccosmoking/en/">lower</a> than in other countries in the west African region. Nevertheless, tobacco use is still considered to be a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069749/">public health threat</a>. It’s estimated that between 5% and 8% of the country’s population smokes.</p>
<p>In 2004, Ghana was among the first few countries to ratify the <a href="https://www.who.int/fctc/text_download/en/">World Health Organisation (WHO) Framework Convention on Tobacco Control</a>. The treaty was developed to spearhead the global response to the tobacco epidemic. But the country has been slow to implement many of the articles in the convention. These include recommendations on excise taxes as well as the introduction of pictorial warning labels on cigarette packs.</p>
<p>It’s a welcome move that Ghana – even belatedly – has moved on at least one of the interventions recommended by the WHO: the introduction of warning labels. The WHO <a href="https://www.who.int/tobacco/healthwarningsdatabase/en/">recommends</a> the use of full-colour images. These include pictures depicting various body parts affected by diseases related to tobacco use.</p>
<p>We conducted a qualitative <a href="https://www.ncbi.nlm.nih.gov/pubmed/25114265">study</a> in 2014 – prior to the introduction of pictorial warnings. The research was done by the Kwame Nkrumah University of Science and Technology’s School of Public Health along with colleagues from the Food and Drugs Authority. Our findings showed that both smokers and non-smokers felt a combination of both pictures and words was more effective than just words on their own or just pictures on their own in conveying the health dangers of tobacco. </p>
<h2>What’s been done</h2>
<p>Ghana’s tobacco control measures are governed by the <a href="https://www.modernghana.com/news/405747/public-health-bill-tobacco-control-measures-passed-by-parl.html">Public Health Act of 2012</a>. The act legislates several aspects such as smoking in public places, tobacco advertising as well as packaging and labelling.</p>
<p>In 2016 the country’s Food and Drug Authority made use of the act to compile the <a href="https://www.tobaccocontrollaws.org/files/live/Ghana/Ghana%20-%20TC%20Regs%202016%20-%20national.pdf">Tobacco Control Regulations</a>. Provisions introduced under the regulations mandated the tobacco industry – tobacco product manufacturers, wholesale distributors and importers – to ensure that all tobacco packaging had health warning labels in the form of a picture and text. </p>
<p>The stipulation was that warnings must cover 50% of the front and 60% of the back of all packaging. The industry was given 18 months from January 2017 to comply with the new rules.</p>
<p>These regulations supplemented rules introduced in 2010 that required text-only warnings on cigarettes packages. All tobacco products sold in Ghana are now required to have pictorial as well as text warnings.</p>
<p>Ghanaian authorities are also taking special measures to ensure that pictorial health warnings are implemented successfully. For example, the Food and Drugs Authority embarked on successive nationwide sensitisation and training for all law enforcement agencies such as the police, customs, judiciary, Ghana Health Service, opinion leaders and all stakeholders involved in tobacco control to raise awareness of the pictorial health warnings. </p>
<h2>Impact</h2>
<p>The introduction of the pictorial warnings forms part of a new education campaign in the country to increase people’s knowledge about tobacco use.</p>
<p>It’s too soon to tell what difference the warnings will make to tobacco consumption, if any. But we were able to establish initial reactions to the new packaging by conducting interviews with stakeholders in tobacco control on the introduction of the pictorial warnings.</p>
<p>It is suggested that the new packaging could help Ghana curb the health, social, environmental and economic consequences of tobacco use.</p>
<p><em>Olivia Agyekumwaa Boateng, Head of Tobacco & Substance Abuse at the Food and Drug authority in Ghana, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/116845/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana is the latest country in Africa to mandate the use of pictures on cigarette packages to convey health warnings.Ellis Owusu-Dabo, Associate Professor, Kwame Nkrumah University of Science and Technology (KNUST)Arti Singh, Phd Candidate, Kwame Nkrumah University of Science and Technology (KNUST)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/786592017-07-18T00:24:00Z2017-07-18T00:24:00ZWarnings on US cigarette packs not as effective as those in other countries<figure><img src="https://images.theconversation.com/files/174580/original/file-20170619-22101-13dmes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Do you know what's in your cigarettes?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/287436329?src=zB-ntm1eqxxX_R5Xe9VvQA-1-55&size=huge_jpg">Pe3k/Shutterstock</a></span></figcaption></figure><p>Cigarette smoke contains more than <a href="https://www.crcpress.com/The-Chemical-Components-of-Tobacco-and-Tobacco-Smoke-Second-Edition/Rodgman-Perfetti/p/book/9781466515482">9,000 chemicals</a>, including more than 60 carcinogens. According to the U.S. Food and Drug Administration, there are <a href="https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/ucm297786.htm">93 harmful and potentially harmful chemicals</a> found in tobacco products.</p>
<p>But, when asked, adults in the U.S. can name only a few, such as <a href="https://doi.org/10.1093/ntr/ntv281">tar and nicotine</a>. How can we ensure that more smokers are aware of the risks? My team’s research suggests that we can look to other countries for an answer.</p>
<h1>Labels around the world</h1>
<p>To increase the public awareness of toxic chemicals in tobacco products, the <a href="http://www.who.int/fctc/guidelines/Guideliness_Articles_9_10_rev_240613.pdf">World Health Organization (WHO)</a> recommends that countries warn the public about toxic ingredients in tobacco products through <a href="http://www.who.int/fctc/guidelines/article_11.pdf">large warnings with pictures</a>.</p>
<p>According to a study with a U.S. national sample of adults, health warning labels on cigarette packs are the primary way <a href="https://doi.org/10.1186/s12889-016-3151-5">consumers prefer</a> to obtain information on chemicals in tobacco products. Warning labels can
inform consumers – both current smokers and susceptible nonsmokers – at a minimum cost.</p>
<p><a href="http://dx.doi.org/10.1136/tobaccocontrol-2014-051978">Pictorial warnings</a> are superior to text-only warnings, because they catch consumers’ attention and increase their attempts to quit. For example, in a <a href="https://doi.org/10.1001/jamainternmed.2016.2621">randomized clinical trial</a>, 40 percent of adult smokers who received pictorial warnings attempted to quit smoking, compared to 34 percent of those who received text-only warnings. While this appears to be a small difference, the difference is still meaningful given that warnings can reach a large number of people. </p>
<p>As such, more than <a href="http://www.tobaccolabels.ca/wp/wp-content/uploads/2016/11/Cigarette-Package-Health-Warnings-International-Status-Report-English-CCS-Oct-2016.pdf">100 countries</a> in the world have implemented pictorial warnings, consistent with the WHO recommendations. Among the over 100 countries, Nepal, Vanuatu, India, Thailand and Australia are leading other countries in terms of the size of the warnings.</p>
<p>Despite these benefits – and the fact that consumers <a href="https://doi.org/10.1007/s10865-017-9823-5">want to know more</a> in learning about toxic chemicals in cigarette smoke – the U.S. has not introduced graphic warnings.
The U.S. has also not introduced any novel warning message on harmful and potentially harmful chemicals in cigarette smoke. In fact, its four required warnings have not changed since 1984. Of those four, there’s only one message about toxic chemicals: “Cigarette smoke contains carbon monoxide.”</p>
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<p>Other countries, meanwhile, are making efforts to present consumers with graphical information about toxic chemicals other than carbon monoxide. </p>
<p>Mexico, for example, introduced pictorial warnings on cigarette packs with specific statements about the dangers of toxins in 2010. Their warnings describe where toxic chemicals can be found in products other than cigarettes: “Contains Formaldehyde: a toxin that is used to preserve dead bodies.” Mexico also changes its warnings more frequently than any other country in the world, rotating new warnings every three months.</p>
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<img alt="" src="https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=719&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=719&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=719&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=903&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=903&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177228/original/file-20170706-26461-13wrl0t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=903&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Cigarette labels with images, like this one from Australia, have been shown to be more effective than text-only warnings.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Australian_cigarette_pack_with_health_warning_December_2012.jpg">Jack Greenmaven</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Since 2012, Australia has also required large pictorial warnings that cover over 80 percent of the cigarette pack. Meanwhile, U.S. warnings on average cover <a href="http://www.tobaccolabels.ca/wp/wp-content/uploads/2016/11/Cigarette-Package-Health-Warnings-International-Status-Report-English-CCS-Oct-2016.pdf">very little of the total cigarette pack</a>.</p>
<p>Australia also standardized the size and color of cigarette packs and introduced descriptive warning messages in yellow color about toxic chemicals. The <a href="https://www.legislation.gov.au/Details/F2013C00598">warnings</a> describe how toxic chemicals in tobacco smoke cause disease: “Inhaling tobacco smoke releases benzene into your body. Benzene causes leukemia, increases the risk of other cancers and is believed to be dangerous at any level of exposure.” </p>
<p>In 2012, Canada replaced warnings about the quantitative levels of toxic chemicals with short statements about the presence of those chemicals. This followed a study showing that the numerical amount of tar and nicotine emission displayed on cigarette packs in many countries was <a href="https://doi.org/10.1016/j.puhe.2012.03.012">misleading</a>. While smokers often believe that “light” cigarettes are safer than others due to their low nicotine quantities, they are likely to inhale the same amount of <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/">chemicals</a> from light cigarettes as regular cigarettes. This is because the amount of chemicals inhaled by a smoker depends on <a href="https://doi.org/10.1093/jnci/93.2.134">the individual smoker’s puffing behavior</a>.</p>
<h1>International comparisons</h1>
<p><a href="http://journals.sagepub.com/doi/full/10.1177/1090198117709884">Our new study</a> looks at online survey data from more than 4,000 adult smokers in Australia, Canada, Mexico and the U.S. We found that smokers’ knowledge of toxic chemicals described on each country’s warnings significantly increased between 2012 and 2014 in all countries but the U.S., after the countries added information about toxic chemicals to cigarette packs.</p>
<p>For example, as of September 2012, the average smoker in Mexico did not know that any of the three chemicals listed on cigarette packs – cyanide, formaldehyde and radioactive polonium 210 – was in cigarette smoke. However, in January 2014, smokers on average knew at least one, our study found.</p>
<p>Our results suggest that descriptive information about toxic chemicals can enhance smokers’ understanding of smoking-related risks. In our study, smokers’ perceptions of their risk of smoking-related conditions listed on packs – such as heart disease – increased over time in Australia, Canada and Mexico - but not in the U.S. </p>
<p>Moreover, smokers who knew more toxic chemicals and took a closer look at the warnings were also more likely to know about related health risks and believe that they were at a higher risk than nonsmokers – with the U.S. again the exception. </p>
<h1>Moving forward</h1>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177229/original/file-20170706-7671-qaikl0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cigarettes in the European Union feature blunt warnings about the dangers of smoking.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Marlboro_warning_death.jpg">Mdd4696</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>There is more we can do to identify communication strategies that discourage smoking and maximize public understanding of toxic chemicals. For example, we do not know whether it is more effective to describe how chemicals lead to disease or to note where toxic chemicals can be found in daily products. </p>
<p>Still, it appears clear that there’s plenty of room for improvement on U.S. cigarette pack warnings. </p>
<p>Given the effectiveness of pack warnings and the public desire to learn more about toxic chemicals, our research shows it would be beneficial to include more descriptive information about toxic chemicals in cigarette smoke in U.S. warnings. Large, graphic and often-rotated warnings would be ideal, as we have learned from other countries.</p><img src="https://counter.theconversation.com/content/78659/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yoojin Cho does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Do US smokers really know the risks? Research from Australia, Canada and Mexico shows that there are better ways to warn consumers.Yoojin Cho, Doctoral student in Health Promotion, Education, and Behavior, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/582392016-04-22T10:21:15Z2016-04-22T10:21:15ZMars makes bold food label move, but people may not do what it says on the tin<figure><img src="https://images.theconversation.com/files/119677/original/image-20160421-27019-y14tyt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Quinoa, obviously. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/roeyahram/3208735470/in/photolist-5TxBgm-nAkhwY-6JZB6Z-5842QF-coTdzG-7yq2Gx-8X4jUb-5RAVj7-4xMVQG-jFJ8xi-9Eqx25-ebgHTP-HcH1r-dV4Ps9-5BKkCn-4yfR3R-7UHNqv-69npy-29GXhX-a55t3b-6io1bq-bE37qr-64TC2-5XPYSV-9n81y3-3aJeV6-5wrKY2-7jmJ7t-6WjTF5-br8k13-6jwq2B-4zLYzB-pVib7B-azscE5-bCdXQK-54ug3q-9vLQEn-eHkQBF-6K4GKy-qXTzV-6F1koS-edNBRD-5ww5rJ-3Pp453-6XbytL-8wc5u-bXzT1-Cj3tz-54CBAL-EVXTk">Roey Ahram</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The move by food group Mars <a href="http://www.theguardian.com/society/2016/apr/15/dolmio-eat-occasionally-labels-thought-to-pre-empt-childhood-obesity-plan">to introduce a worldwide labelling scheme</a> that categorises its products as “occasional” and “everyday” based on their sugar, salt and fat content, is both unusual and potentially risky. The American company is behind products including Uncle Ben’s rice and Dolmio pasta sauces, though the chocolate ranges it is also known for aren’t part of this new initiative.</p>
<p>The plan to label around 5% of the Mars <a href="http://www.mars.com/global/brands/food.aspx">mealtime products</a> as “occasional” may mean the public will perceive them to be unhealthy where they didn’t before. This could harm sales of certain Dolmio savoury sauces, <a href="http://www.bbc.co.uk/news/uk-36051333">for example</a>, even though they are <a href="http://www.independent.co.uk/news/uk/who-else-is-saying-some-of-their-delicious-produce-should-be-eaten-only-once-a-week-a6986626.html">by no means</a> the <a href="http://www.bbc.co.uk/newsbeat/article/36054494/six-everyday-things-with-more-sugar-than-dolmio-lasagne-sauce">least healthy</a> on the market. </p>
<p>Though Mars says it will reformulate the “occasional” products to make them healthier, I cannot think of another example of a company voluntarily introducing a labelling system that has the potential to reduce sales like this. Existing product labels are either the result of government diktat, such as <a href="http://www.ash.org.uk/current-policy-issues/harm-reduction-product-regulation/warning-labels">cigarette health warnings</a> or the UK’s nutritional <a href="http://www.nhs.uk/news/2013/06June/Pages/universal-colour-coded-food-nutrition-labels.aspx">traffic-light packaging</a> – or they are used to advertise a positive quality, <a href="http://industry.freedomfood.co.uk/rspca-welfare-standards">such as welfare standards for meat</a> or <a href="https://www.msc.org/">fish</a>. </p>
<p>This being the case, how big a risk is Mars really taking here? Do people pay attention to the labelling on packaging? And will they trust or respond to Mars’s new system more than any other food labels?</p>
<h2>What the surveys say …</h2>
<p>The jury is still out, is the short answer. In the UK, the market-research group Mintel <a href="http://www.foodnavigator.com/Market-Trends/Half-of-UK-consumers-do-not-trust-the-food-industry-on-safety-Mintel">reported</a> in 2013 that only 49% of consumers trusted manufacturers to provide safe food; while DJS Research in 2015 <a href="http://www.djsresearch.co.uk/FoodMarketResearchInsightsAndFindings/article/Survey-finds-Britons-want-more-information-on-food-labels-02392">found that</a> 47% of UK consumers wanted companies to put more information on food packaging. Another 44% said they would trust manufacturers more if they supplied more information. </p>
<p>This may be at odds with a <a href="http://www.nielsen.com/us/en/press-room/2012/fifty-nine-percent-of-consumers-around-the-world-indicate-diffic.html">worldwide survey</a> of consumers by the Nielsen agency in 2012, which found that 80% see assertions on labels as sometimes or never believable. </p>
<p>An American survey of 1,500 people by the advertising agency Sullivan, Higdon and Sink pointed to some moderately better news for Mars. It <a href="http://www.hoards.com/sites/default/files/Evolving-TrustInFoodIndustry.pdf">found that</a> Americans’ trust in food manufacturers’ transparency about how they made their products had climbed from 17% in 2012 to 34% in 2015 – albeit this still meant the majority of people didn’t trust them. </p>
<p>A <a href="http://www.foodnavigator-usa.com/Manufacturers/Why-don-t-consumers-trust-big-food-asks-Center-for-Food-Integrity">survey of more than 2,000 Americans</a> in 2015 by the industry-funded <a href="http://www.foodintegrity.org">Center for Food Integrity</a>, meanwhile, reported an inverse relationship between the size of a commercial farm and the extent to which consumers think they have values in common. The bigger the farm, in other words, the more people perceive it to be putting profits ahead of consumer interests. It seems likely that the same would apply to food manufacturers. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119709/original/image-20160421-26983-sgnvsa.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Saucey.</span>
<span class="attribution"><span class="source">Mars Food</span></span>
</figcaption>
</figure>
<h2>Enough already?</h2>
<p>Another issue is whether Mars’s proposal to categorise products as “occasional” or “everyday” is precise or clear enough. The company <a href="http://www.mars.com/uk/en/press-center/press-list/news-releases.aspx?SiteId=94&Id=7115">suggests that</a> “occasional” means you should only eat it once a week. But do people follow this kind of broad-brush messaging?</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=778&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=778&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=778&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=978&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=978&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119681/original/image-20160421-27001-1gi67hq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=978&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">And breathe out …</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/s/cigarette+warning/search.html?page=2&thumb_size=mosaic&inline=263758799">Nuttapong</a></span>
</figcaption>
</figure>
<p>The UK government’s “five-a-day” message about fruit and vegetables is <a href="http://www.immediate.co.uk/news/brand/nearly-two-thirds-of-population-do-not-eat-5-a-day-indicates-bbc-good-food-study/">not followed</a> by two-thirds of the UK population. A message that can be tested over a longer period is cigarette packaging warnings, which <a href="http://news.bbc.co.uk/1/hi/health/4377928.stm">date back</a> to the 1970s, though these came at the same time as other anti-smoking initiatives. <a href="http://tobaccocontrol.bmj.com/content/15/suppl_3/iii19.short">One survey</a> of consumers in the UK, US, Canada and Australia by International Tobacco Control in 2005 found that people who noticed the warnings were more likely to believe they were true. Yet after decades of warnings, most smokers were still not fully informed about the risks of smoking. </p>
<p>As far as Mars is concerned, there is also the question of how the “occasional” message is interpreted. It will be interesting to see whether it is taken to mean, “eat once a week or less”, which is the spirit of the message, or “I can eat this every week”. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=352&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=352&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=352&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=442&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=442&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119683/original/image-20160421-27001-1601gm1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=442&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Mars Inc</span></span>
</figcaption>
</figure>
<p>Past consumer surveys suggest Mars may not be trusted due to its size, albeit its attempt at transparency might act in its favour. It is possible that the messages will prompt consumers to eat more healthily, but don’t be surprised if most carry on regardless. No doubt Mars’s rivals will be watching with interest to see what happens. As for the Mars Bar, it has stayed mostly out of the limelight since the initiative was announced. Whether this can continue, time will tell. Where once the company told us that “a Mars a day helps you work, rest and play”, there now seems to be a strong argument for moving the flagship chocolate bar into the “occasional” category.</p><img src="https://counter.theconversation.com/content/58239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Norman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is a curious paradox at the heart of the food group’s new nutrition scheme: the less consumers trust Big Food, the less attention they will pay to the labels.Rachel Norman, Chair of Food Security and Sustainability, University of StirlingLicensed as Creative Commons – attribution, no derivatives.