Warning: warnings often ineffective!

The responses to December’s Question indicate that the tobacco industry has expressed relatively little opposition to health warnings on cigarette packs, as long as they are small, general, and on the side of the pack. This is also true in countries where the majority of smokers buy cigarettes individually or have low literacy rates. In some cases, the industry has voluntarily agreed to add health warnings, probably due to legal concerns about future lawsuits. What type of warning labels does the tobacco industry fight? Large, bold, graphic, specific warnings, e.g. smoking can cause sexual impotence.

This is an appropriate time to congratulate our friends in Canada. At the end of last month, the Canadian government unveiled the world's strongest cigarette warnings. All cigarette packs and cartons are now required to carry one of 16 strong, specific, rotating warnings. Each takes up 50% of the pack and utilizes hard-hitting graphics. The Non Smokers Rights Association of Canada has posted on the web examples of the new Canadian cigarette warnings. You'll definitely want to check these out! See http://www.nsra-adnf.ca/english/warnexamples.html

For more information comparing cigarette labeling laws around the world and the double standard between U.S. tobacco corporations' labels in the U.S. vs. abroad, check out Public Citizen's short report (1998) at http://www.citizen.org/hrg/PUBLICATIONS/tobacco/tobacco.htm

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SUMMARY of DECEMBER 2000's QUESTION OF THE MONTH
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This summary is meant to provide a general international comparison of cigarette warning labels. All information and statistics are supplied by participants in Essential Action's Global Partnerships for Tobacco Control program. For more detailed information about each country, please contact Essential Action.

Health Warning Requirements

All groups that responded said that cigarette packs carry health warnings in their country, however, not all warnings are mandated by law nor are they always present. According to Philip Karugaba of Uganda, "There is no legal requirement. The warning is carried as a result of discussions between the Ministry of Health and the tobacco companies. As a result of this unfortunate approach, the tobacco companies got to dilute the warning and attribute it to the Ministry of Health." Maniphanh of ADRA Laos reports that only two out of ten brand name cigarette packets have health warnings.

Content of Warnings*

In the majority of countries, the health warning is basic, e.g. "smoking is harmful to your health" or "smoking is dangerous for health" (Bangladesh, Cameroon, Congo, Czech Republic, Georgia, India, Indonesia, Kenya, Laos, Pakistan, Papua New Guinea, Romania, Uganda, Ukraine, Uruguay, Yugoslavia, Zambia, Zimbabwe). In at least nine countries (Bangladesh, Congo, Czech Republic, Kenya, Pakistan, Papua New Guinea, Uganda, Ukraine, USA) the warning is prefaced with the words "Government warning:" or "Ministry of Health warning:" or "Surgeon General's warning:" A few countries cite specific health consequences of smoking and use rotating warnings. Canada and Thailand have the strongest warning labels, which include information on addiction, sexual impotence, and smoking's harm to loved ones. A sampling of the some of the more specific warnings:

Canada - 16 different warnings. For content of the warnings: see
http://www.nsra-adnf.ca/english/warnexamples.html
Thailand - We have 10 warning statements: 1. Smoking causes lung cancer. 2. Smoking causes heart failure. 3. Smoking causes pulmonary emphysema. 4. Smoking causes cerebrovascular disease. 5. Smoking leads to narcotic addictions. 6. Smoking reduces sexual ability 7. Smoking causes premature aging. 8. Smoking kills. 9. Smoking is harmful to your close ones. 10. Smoking is harmful to the fetus
USA - "SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy" or "SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health." or " SURGEON GENERAL'S WARNING: Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth and Low Birth Weight." Or "SURGEON GENERAL'S WARNING: Cigarette Smoking Contains Carbon Monoxide."
Georgia - The content differs on various cigarettes, but the main text says: "Ministry of Health Warns that smoking is harmful to your health." Then: "Smoking causes premature death" or "Smoking causes cardiovascular diseases" or "Smoking causes lung cancer."
Bahrain – "Smoking is a main cause for lung cancer, heart failure, and atheroscelerosis"
Korea - 1. "Smoking causes lung cancer and various other diseases. It is particularly harmful to the health of adolescent and pregnant women" (front) 2. "Selling tobacco to adolescent under 19 is prohibited" (back)
Cameroon - "Tobacco may be dangerous to your health" or "Stopping smoking reduces the risk of serious disease." *We did not specifically ask whether or not warnings include levels of tar and nicotine.
Indonesia - Based on the new regulation, it should be "Smoking can cause heart disease, lung cancer, cerebro vascular disease and impotent". But, some of thecigarrettes sold still use the old warning, " Smoking may damage your health"

Size, Color & Placement of Warnings

None of the warnings carry any graphics, with the exception of Canada's new warnings. Warnings range in size from 5% (Romania) to 50% (Canada) of a cigarette pack. Font size is typically small (8-10 point), with the exception of Thailand which mandates font sizes between 20 and 38 point. Warnings are usually positioned on the side of the pack, with the exception of Canada, Cameroon, Korea, Romania, Thailand, Uruguay, and Zambia. The colors vary according to country and cigarette brands, often matching the overall color scheme of the packet, or contrasting as little as possible, e.g. gold or yellow type on a white background. Canada, Korea, and Thailand require black and white warnings. Countries & warning characteristics, listed in approximate order of size:

Canada - Size: 50% of pack
Thailand - Size: Area not less than 1/3 of the front and the back of the pack or carton. Packs with front area les that 37 square cms. Must use 20 point font. Above 37 square cms, 25 point font. Above 80 square cms, 38 point font. Color: Frame should be white and 2 mm.wide, label background should be black with white letters front and back .
Cameroon - Size: 2 cm wide and 6 long. Color: yellow on blue packs, white on green packs. Position: vertically visible on left corner of each cigarette pack
Pakistan – Size: 52mm x 14 mm, letters not less than 3 mm in height. Color. Varies but must have border around. Position. Both sides, nothing else mentioned on these sides beside number of cigarettes in pack.
Czech Republic - Size: 10 x 50 mm, i.e. 10% of the front side Color: Gold type on a white background front and back
India - Size: less than 1/4 the size of a cigarette box. Color: Usually light golden in colour back of the packet
Uruguay - Size: less than 15% of surface. Color: black. Position: Front, bottom
Papua New Guinea – 9 point font. Color:
Georgia - Size: equal to 8 point font of Times New Roman. Color: May be black, golden or red on the white backgrand side
Romania - Size: 5%. Color: white. Position: front. Color: black. Position: one side of the pack
Laos – Size: 12 point font Times New Roman. Color: red. Position: both sides
Indonesia - Size: total width about half of the wide area. Position: side. Color: blue.
USA - Color: usually matches color scheme of pack. Position: one side of Pack
Ukraine – Size: typically very small. Color: varies, Marlboro, the most popular foreign brand is in red. Position: right or left side.
Kenya - Size: very small - "so tiny that CTFED wonders how many Kenyans read or even see it." Color: usually black on white, red or green depending on the color of the pack. Position: side of pack – Fred Odhiambo.
Color: very small letters either red, blue or black, depending on the colour of the pack. "You may wish to know that imported cigars like Sweet Nuts, Wills legation Navy Cut, Sundowner have no warning on their packs!" -- George Banja
Korea - Size: lower one third of the surfaces of a pack. Color: Black and bold surrounded by a black square line. Position: both sides
Vietnam - Health warnings must be impressive, highly visible and carry a strong, brief message. In the future must also indicate hazardous contents (nicotine, tar) Position: one side of pack. For imported cigarettes such as 555, the warning label is on one side of the packet, but in a foreign language and it confusing as most people don't understand that language
Uganda - Size: no stipulation, generally done in capital letters, 10 font no stipulation. Color: generally done in black. Position: one side It also appears following tobacco adverts on radio tv, and in the print media. On tv it appears in text with a voice message as well.
Papua New Guinea – Size: 9 point font. Color: Chosen to NOT stand out, e.g. Kool is gold on white, Winfield is dull gold on red. In general the content warning has more of a color contrast than the health warning. "The companies don’t care – it is meaningless to most people [15 mg CPM or less 1.5 mg nicotine or less as per government agreed method]. Especially when tar is hidden under a euphemism which even I had to look up: CPM [Corrected Particulate Matter]."
Zambia - Size: Font size 8. Color: Green/Blue. Position: not conspicuous Front
Yugoslavia - Size: small. Color: usually gold colored on the white background. Position: There are two types: first type is one with the contents on the side of the pack, and the other is with the warning placed on the front side of the pack
Congo - Color: Black. Position: horizontal
Bangladesh - "The law only says that the warning should be prominent. It doesn't mention size or placement, so companies place it on one side of the pack, in small print in contrasting colors (but not white on black or vice versa). For instance, Senor Gold is white on red, and B & H is copper on tan."

Language of Warnings & Literacy Rates

In general, health warnings are printed in the main national language, however, literacy rates are low in many countries which further reduces the effectiveness of the warnings. Bangladesh, India, Kenya, and Zambia, for example, all have literacy rates under 60% in their health warning's language. Health warning languages, listed in order of literacy rates:

Czech Republic - Czech, 100%
Thailand - Thai, 100%
Ukraine – Ukrainian, 100%
Canada - French & English, English is the mother tongue of 22 million, French is the mother tongue for 7 million. In Quebec, 6 out of 7 people's mother tongue is French
Georgia - Georgian, 99%
Uruguay - Spanish, 98%
USA - English, 97%
Yugoslavia (Serbia and Montenegro)- Domestic packs are in Serbian language, 90%
Philippines - English, 90%
Vietnam - Vietnamese, except in some special cases, news, radio & television (if in foreign language). Vietnamese must be first, above, font size bigger, 89.4% (1997-98)
Korea - Korean, Illiteracy is less than 15% (1997)
Cameroon - English & French, 83%
Romania - Romanian, 80%
Indonesia - Indonesian language, 80%
Zimbabwe – English, 60%
Zambia - English, 56% in 1990, since then the education sector has deteriorated
Pakistan – English & Urdu, 47%
Kenya - English (official language), and Kiswahili (a national language), 45% English, 39% Kiswahili. The other majority can only talk and understand either of the language, but are unable to read, hence the warnings are not effective
Bangladesh - Bengali, except imported (and smuggled) cigarettes). Most speak, but the literacy rates is less than 50% for men, and perhaps only 20% for women
India - English, About 20% is literate in this language
Congo – French, 15.5% in the capitol
Papua New Guinea – English, majority speak Tok Pisin or Hiri Motu (English is only widely spoken by the educated classes) There are 800 tribal languages.
Laos – English and Lao. Imported cigarettes for Singapore are in English.
Uganda - English & Swahili, don't know

How do most people purchase cigarettes -- in the pack or individually?

People purchase cigarettes in quantities according to their financial means. This explains why people in rich countries are most likely to purchase cigarettes in packs or cartons, while people in poorer countries are more likely to buy cigarettes individually. We can assume that health warnings on packs in countries where people mostly buy cigarettes individually have little or no effect. Here's how the countries break down:

Packs - Canada, Czech Republic, Korea, Thailand (officially), Ukraine, Uruguay, Yugoslavia *
Both - India, Indonesia, Pakistan, Philippines, Romania, Zambia, Zimbabwe **
Individual - Bangladesh, Cameroon, Congo, Kenya, Laos, Uganda, Vietnam ***

*Canada- Canadian laws forbid sale of cigarettes individually, kiddie packs, etc. Cigarettes must be sold in packages containing at least 20 cigarettes
**In India, Indonesia, Philippines poor people buy cigarettes individually, middle and high income people buy them by the pack. In Pakistan, young people are inclined to buy cigarettes individually, while the older working class buys them in the pack.
***Kenya- "Most people purchase cigarettes singly and not in packs. Local tobacco executives tend to encourage this since they want many Kenyans to afford cigarettes. The common man buys singly and even shares one cigarette, which further endangers human health." (Fred Odhiambo) "In rural areas, cigarettes are purchased individually, This is also true for low income earners in urban areas. Those in upper income brackets purchase their cigarettes in packs." (George Banja)
Vietnam- "Buying cigarettes individually or in the pack depends on the economic status of the smoker. Until now, there is no research on the issue. Through observation, we recognize that most smokers buy cigarettes individually."

Smuggling & Health Warnings

Many groups that responded acknowledged that cigarette smuggling is a big problem in their countries -- as many as 80% of cigarettes in Yugoslavia are smuggled! Sometimes smuggled cigarette packs have weaker warnings, sometimes stronger warnings (though usually in a language most people are not literate in). Philip Morris brands are smuggled in Kenya, Pakistan Thailand, Uruguay, and Yugoslavia. BAT brands are smuggled in Bangladesh, India, Kenya, Pakistan, Vietnam,and Yugoslavia.

Bangladesh - "Smuggling is a big problem.The most commonly smuggled cigarettes are Benson & Hedges. An imported or smuggled pack has the warning in English."
Czech Republic - "In 1999, 50 million cigarettes smuggled into the country were seized. It is estimated that this is one 1/10 of total smuggled -- 1/2 billion cigarettes annually, i.e. 2.2% of all cigarettes consumed"
India - "Not a major problem, Benson & Hedges and Dunhill are common brands smuggled"
Kenya - "Cigarette smuggling is a problem in Kenya at cross boarders, through airliner passengers carrying allowed "duty-free" items. Some of our leading export passenger brands are exported and again end up at cross-borders selling at very low prices. Winston lights, Kool natural lights, Kings, Benson & Hedges, Newport Slims, 120 Kent, 555 international (state Express), Aspen, and Japanese brands. They differ greatly in their health warnings, e.g. Benson & Hedges display Surgeon General's warning "Quitting Smoking Now greatly Reduces Serious Risks to your health" and indicates the content 15 mgg tar 11, mg nicotine. The locally packed Benson and Hedges does not have such strong warnings. The same applies to 555 International, Kent and the rest. There are big differences. KOOL natural lights displays "Surgeon General's warning: Smoking causes Lung Cancer, Heart Diseases, Emphysema and May Complicate Pregnancy, Content 8 mg tar, 0.6 mg nicotine." (Fred Odhiambo)
Pakistan – "Smuggling is rampant near the borders of the country and the effects trickle down to the more centrally located areas. The markets of Balouchistan and North West Frontier Province deal primarily in foreign brands, which are mainly Dunhill, Camel, Silkcut, More, Marlboro, and almost all other brands available internationally. These brands do not carry warnings in the national language. Warnings in English are poorly understood by the majority of the population."
Philippines - "All brands from different points of the world. Some, aside from English, would be in the local dialect of the country of source. "
Romania - "Bulgarian tobacco and Kent, neither have warnings"
Thailand - "Marlboro, most have no health warnings"
Uganda - "Smuggling is an issue in Uganda. I am not sure what brands are most smuggled, but I have seen stories on SuperMatch and Sportsman which are both local brands"
Uruguay - "Smuggling is a problem, Marlboros is one of them"
Vietnam - "Smuggling still is a hot problem in some border province in our country. On October of this year, Vietnam television aired the smuggling in some border provinces Set, White Horse and 555.There is no difference between legally sold and smuggled sold cigarettes."
Yugoslavia (Serbia and Montenegro) - "80% of cigarettes are smuggled. The brands that are smuggled most are: Marlboro, Lucky Strikes, Pall Mall, Winston, LM, Bond, Eve, and many others. On the foreign packs of cigarettes warnings offer more information about disease and complications which smoking may cause. For example: "Smoking Causes Lung Cancer, Heart Disease, Emphysema, May Complicate Pregnancy"
Zimbabwe – Cigarette smuggling is a problem. The smuggled brands are home-made brands which bear no warnings and are illegal so they are sold on the black market.

Tobacco Industry Opposition to Health Warnings

As a general rule, the tobacco industry fights tobacco control measures that it knows to be the most effective reducing smoking rates. Not surprisingly, of all the countries that responded, Canada, with it's new, strong, graphic warnings, has felt the greatest resistance from the tobacco industry. Most countries have faced little or no opposition from the tobacco industry (Congo, Georgia, Korea, Pakistan, Romania, Ukraine, Yugoslavia, Zambia). Several, as in the case of the Czech Republic and Uganda (mentioned above), have negotiated voluntary health warnings with the industry. Countries listed in approximate order of most to least industry resistance:

Canada - "The tobacco industry had all its allies speak loudly against the new warnings -- corner store associations (loss of thousands jobs), printers (unable to print the new warnings, tobacco industry workers unions (loss of jobs). They also went to court to get the autorisation to postpone (23 dec) until the Supreme Court of Canada would have heard the case (in 4-6 years from now)."
Uruguay - "Tobacco industry's resistance is huge, to every kind of change in health warnings, but in 3 months new legislations will come into effect. Warnings will be: "Smoking can cause cancer, cardiovascular disease, and emphysema." "Smoking can hurt your baby""
Kenya - "The tobacco industry is opposed to any truth being added to the pack since they are opposed to the proposed Tobacco Control Bill which calls for greater health warnings on the pack"
Zimbabwe – "Cigarette companies resisted these Health warnings but because of pressure from Government … this managed to be enforced."
Bangladesh - "I don't know, but of course they oppose everything useful. A lawsuit that would require them to increase the size of the warnings, as well as do many other things, is currently under appeal"
India - "Cigarette packs have been carrying the warning for many years, however the companies resist writing more specific warnings and also in the local language."
Indonesia - "As a whole the tobacco industry opposed to the regulation related to smoking control, eventhough the issued raised was mostly on the tar and nocotine content and raised of the tax, and not about the warning itself. Severals years ago there were a strong opposition to the warning, and the warning was just " smoking may damage your health"
Pakistan – "Since the advertising of tobacco brands is so rampant the tobacco industry didn’t feel so threatened by the printing of these health warnings as they seem to be towards a more general ban on tobacco advertising."
Philippines - "Highly resistant done through lobbying in the house of Representatives."
Ukraine – "In accordance to the law, they are obliged to print the warning so there is no [longer a] question of resistance. But in the law there are no directions on the place, so the manufacturers put the warning on the side, in small font that hampers reading."
Czech Republic - "The first text of the warning was "Smoking causes cancer" in 1992. It was put on the side of the pack, according to a gentlemen's agreement with the tobacco plant."
Georgia - "No open resistance from the tobacco companies was ever shown in our country. However, they seem to have strong hidden pressure on authorities, since a ban on cigarette advertisement via mass media and billboards lasted only for several months."

Many thanks to the following Global Partnership for Tobacco Control participants:

Bahrain - Salah A. Abdulrahman, Ministry of Health
Bangladesh - Saifuddin Ahmed, Work for a Better Bangladesh
Cameroon - Alphonse Issi, Mouvement National des Consommaturs (MNC)
Canada - Louis Gauvin, Coalition Quebecoise pour le Controle du Tabac
Congo - Itamponi Micheline, Bons Templiers Congolais
Czech Republic - Jiri Kozak, Czech Committee of EMASH - European Medical Association on Smoking or Health
Georgia - Eteri Suladze, Society Development International Foundation
India - Renu Dhasmana, Indian NGO
Indonesia - Tjandra Yoga Aditama, Indonesian Smoking Control Foundation ("Lembaga Menaggulangi Masalah Merokok - LM 3")
Kenya - Fred Odhiambo, Centre for Tobacco-Free Education and Development (CTFED)
Kenya - George Banja, Consumer Watch
Korea - Jin Sook Choi, Korean Association on Smoking and Health
Laos – Maniphanh, ADRA Laos
Pakistan – Ehsan Latif, TFI – Pakistan, Network for Consumer Protection
Papua New Guinea - Colin Richardson, Adventist Health Department
Philippines - Bobby del Rosario, D.R. & Associates, Co.
Romania - Florin Mihaltan, Romanian Society of Pneumology
Thailand - Varabhorn Bhumiswadi, Institute of Tobacco Consumption Control
Uganda - Phillip Karugaba, The Environmental Action Network Ltd. - Actions Against Tobacco
Ukraine - Oleg Samchishin, Ukrainian Consumer Association
Uruguay - Eduardo Bianco, Sindicato Medico del Uruguay
USA - Ted Collins, Private Social Work Practice/Red Ribbon Coalition
Vietnam - Le Thi Thu, PATH Canada - Vietnam
Yugoslavia (Serbia and Montenegro) - Andjelka Dzeletovic, Institute of Public Health of Serbia
Zambia - Muyunda Ililonga, Zambia Consumer Association
Zimbabwe – Johannes Maronda, The Consumer Council of Zimbabwe

For more detailed information about each health warnings in the countries listed above, please contact:
Anna White
Global Partnerships for Tobacco Control
Essential Action
P.O. Box 19405
Washington, DC 20036
Tel: +1 202-387-8030
Fax: +1 202-234-5176
Email: [email protected]