Warnings should include a picture

A snapshot of Europe

Of the 32 European countries requiring at least 30% of principal area to be covered by health warnings in 2007, only 1 (3.13%) required pictorial health warnings. As of May 2009, Belgium, Romania and the United Kingdom use pictorials.

Effectiveness of images

The use of graphic images in addition to text greatly increases the effectiveness of health warnings. Graphic warnings compete more successfully than text-only messages with the rest of the imagery on the package. They make the message more noticeable and help counter the branding and imagery of the package.

Graphic warnings also engage audiences on an emotional level more effectively than text-only warnings and are therefore more likely to motivate behaviour change.

Research on package warnings used in Brazil from 2002 to 2008 showed that, with few exceptions, the most unpleasant and stimulating images were those that most graphically showed physical harm or suffering. Brazil’s third set of warnings, to be implemented in 2009, were tested specifically for unpleasant emotional arousal to ensure a greater potential impact on smokers’ behaviour.

Studies in Canada and the United Kingdom reinforce this finding. As part of its consultations before using pictorial warnings, the United Kingdom Government set up a web site for members of the public to vote for the pictures they felt would be most effective. The images receiving the most votes were those that most graphically showed the negative health effects.

Avoidance of graphic health warnings by smokers does not decrease their effectiveness in motivating behaviour change among them (such as quitting), and may increase it.

Shocking, fear-arousing images can be even more effective when combined with encouragement or empowerment to take action to avoid the fearful outcome. For this reason, many countries have placed quit messages or references to toll-free quitlines on packages in combination with these images. Further evidence supporting the effectiveness of graphic warnings comes from data from calls to toll-free quitline services after graphic warnings are used. Brazil and New Zealand are among the countries that require package warnings to include a toll-free telephone number where people can call for help to stop smoking.

In Brazil, calls to the toll-free quitline number increased nearly ninefold in the six months following the widespread implementation of graphic health warnings on tobacco packaging.

In New Zealand, in the six months following the implementation of graphic health warnings on tobacco packaging, new registrations on the quitline increased by 14% compared with the previous six months. Within three months of introduction, the proportion of new quitline callers who had obtained the number from the package warnings nearly tripled, overtaking the proportion of those who had obtained the number from television advertising.

The Article 11 guidelines to the WHO Framework Convention on Tobacco Control recommend that tobacco packaging include advice on cessation and referrals to cessation resources, “such as a web site address or toll-free telephone ‘quitline’ number”, because these resources can help tobacco users to change their behaviour.

In cultures or countries where there is particular concern about the potential negative impact of shocking images, evidence should be the ultimate guide. A variety of images should be tested among the population. The tests should be guided by what has worked in other countries to see which images are the most effective.

Another benefit of using pictorial warnings is that they can help communicate health information to illiterate or less literate populations, thus helping to reduce disparities in health knowledge.