Health Warnings: Problems with Implementation

According to the World Health Organization, “Health warnings on tobacco packaging, especially those that combine text and pictures, are one of the most cost-effective and powerful ways to increase public awareness of the serious health risks of tobacco use and reduce consumption.”¹ The WHO Framework Convention on Tobacco Control (WHO FCTC) therefore requires all its Parties to implement health warnings describing the harmful effects of tobacco use within three years of signing the treaty.²

The implementation guidelines for Article 11 of the WHO FCTC – which concerns the packaging and labelling of tobacco products – recommend the use of larger graphic health warnings (GHWs), as they are more likely to be noticed than smaller, text-only ones. The guidelines also highlight that GHWs are effective at communicating the harms of tobacco use to young people and those of lower literacy.³

What Does The WHO FCTC Recommend?

While the WHO FCTC provides the minimum requirements for health warnings, the implementation guidelines for Article 11 encourage Parties to go further, drawing on all available evidence and the experience of other jurisdictions, in order to implement the most effective measures.³ Different warnings for different products may be considered, to account for some of the specific health effects of each tobacco product. For example, warnings on smokeless tobacco products tend to focus on oral cancer. Similarly, different health warnings can also target different subgroups of the population, and testing warnings with relevant groups can help ensure effectiveness.³

When designing health warnings, there are several aspects to consider. For example, countries should consider all the available types of packaging – such as tins, boxes, pouches and so on – in their jurisdictions, so they can include specific instructions on how to apply the warnings.³ Other key considerations include the location and size of the warnings, to maximise visibility; fonts and colours, to improve legibility; and rotation of health warnings, to maintain novelty and impact; as well as information on the constituents and emissions of tobacco products, message content, language and source attribution. For more details see the subpage Key Recommendations from the Guidelines for Implementation of WHO FCTC Article 11.

Global Implementation

The 2023 WHO report on the global tobacco epidemic indicates that 103 countries – over half of all countries globally – have implemented large health warnings with all appropriate characteristics.⁴ However, four of the 20 most populous countries in the world have not yet implemented GHWs: China (excluding Hong Kong and Macau), Democratic Republic of the Congo, Japan and the United States (implementation pending).⁵

Globally, the implementation of health warnings on tobacco products has been a success. They are a cost-effective measure, given that costs for implementation are borne by the tobacco industry and tobacco consumers are typically exposed to the warnings several times per day.⁵ However, discrepancies persist across different regions and income levels. Of the 103 countries with large GHWs, 40 are high-income; 57 are middle-income, and 6 are low-income.⁴ And while 77% of consumers in the WHO European Region (EURO) are covered by large GHWs with all the features recommended by the WHO, in the Eastern Mediterranean Region (EMRO) this figure falls to 27%.⁴

In 2022, Tunisia became the first EMRO country to adopt 70% GHWs, the largest in the region, having started with one text warning in 1999.⁴ Myanmar and Benin have also introduced large GHWs in recent years consistent with WHO best practice.⁴ In Benin, GHWs now cover 60% of the front and back panels of all tobacco products, in addition to a text warning that covers 30% of those panels, for a total coverage of 90%.⁴

This progress has come despite tobacco industry attempts to disrupt implementation of health warnings. The industry has repeatedly filed legal challenges against health warnings around the world, citing violation of its right to freedom of expression, expropriation of intellectual property rights, and infringement of trade agreements, amongst other arguments. These legal challenges have mostly been dismissed.⁵ Another industry tactic has been to voluntarily place small text warnings on product packaging in some countries, to dissuade parties from going beyond the minimum WHO FCTC requirements and implementing large GHWs.⁵

Best Practice

While a higher proportion of high-income countries have implemented large health warnings with all appropriate characteristics,⁴ several low- and middle-income countries (LMICs) are now world leaders in implementation of large GHWs. Timor-Leste, Nepal and Maldives, for example, have all introduced GHWs which cover an average of at least 90% of the main panels of tobacco product packaging.⁶ Timor-Leste has also established several additional restrictions to branding on packs (though it did not implement plain packaging), including a base colour for all parts of the pack not covered with warnings. The brand name/logo is only allowed on 15% of the bottom of the front panel in white.⁷

Figure 1: A Marlboro packet from Timor-Leste. Source: Handout/Canadian Cancer Society⁸

Similarly, Turkey introduced GHWs covering 85% of the front panel and 100% back of the back panel in 2021, though this only applies to cigarette packs. For other products, Turkey opted to maintain the GHWs covering 85% of the front and back panels.⁹

In August 2023, Canada became the first country to implement health warnings on individual cigarette sticks.¹⁰

Plain Packaging

Plain packaging is the requirement for tobacco products to be sold only in packaging on which the branding is displayed in a standard size and typeface and all the packaging is the same colour – usually a dull green or brown. Brand logos, colours or any other promotional elements are prohibited. Where it has been introduced, it has usually been accompanied by larger GHWs.¹¹ By the end of 2022, 22 countries had passed legislation mandating plain packaging.

Ongoing Challenges

In 2012, the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health developed the Tobacco Pack Surveillance System (TPackSS) to document the variety of cigarette packaging available in 14 LMICs with the greatest number of people who use tobacco. The project monitors whether the required health warning labels are being implemented as intended and identifies design features and marketing appeals that are still being used on packaging.¹²

Since the initial pack collections in 2013, the TPackSS team has conducted subsequent data collections in countries that have implemented new health warning label requirements and have expanded beyond cigarettes to include bidis, smokeless tobacco, and Brazilian cigarros de palha (straw cigarettes).¹²¹³ As of 2023, over 6,600 tobacco packs had been documented on the TPackSS website.¹⁴

The TPackSS team reports compliance with health warning label requirements for the packs collected and notes areas of concern related to packaging and labelling.¹² The evidence demonstrates that even once health warning labels have been implemented, packaging and labelling requirements may still be subverted or circumvented, whether by the tobacco industry or other actors involved in the production of packaging (though it is the responsibility of the tobacco industry to ensure these measures are implemented correctly).

The section which follows outlines some of the principal challenges with the implementation of health warning labels, providing some examples of non-compliance. However, there may be other practices used to reduce the impact of health warning labels.

All the images used are courtesy of TPackSS.

Poor quality printing and image manipulation

In some cases, the impact of these warnings has been compromised due to poor quality printing and manipulation of images. TPackSS has found examples of images being blurred, stretched or faded (see Figure 2).

Figure 2: Non-compliant health warnings on packets of smokeless tobacco from India.¹⁵¹⁶¹⁷

Figures 3 and 4 also show how official health warnings are sometimes manipulated in order to reduce their impact.

Figure 3: An official health warning from Pakistan¹⁸

Figure 4: In these two packs of cigarettes from Pakistan, the official health warning has clearly been edited.¹⁹²⁰

Tax stamp placement

Tax stamps help governments to know that producers and importers of tobacco products have complied with tax requirements, detect illicit tobacco products and pursue prosecutions in cases of tax fraud.²¹ However, tax stamps have sometimes been placed in ways which reduce the effectiveness of health warning labels (See Figure 5). Tax stamps should be placed where they will be broken when the package is opened to avoid reuse. This has often resulted in them being placed over the front of the health warning label, rather than on the side of the packaging.

Figure 5: Tax stamps obscuring health warnings labels on cigarettes from Viet Nam.²²²³

Packaging design

Another area of concern is the integration of the health warning into the packaging design (see Figure 6), or the presence of branding in the health warning label area (see Figure 7). Though these strategies do not obscure the health warning label and may technically comply with health warning requirements, they may still reduce the overall effectiveness of the policy.

Figure 6: Health warnings on Chinese cigarettes integrated into pack design.²⁴²⁵

Figure 7: Visible branding in the health warning label area on this pack of cigarettes from Viet Nam.²⁶

Text manipulation

There are also cases where the text within a graphic health warning has been manipulated. In the two examples in the left and centre of Figure 8, the yellow text without any outline makes the warning much harder to read, compared to the text on the packet on the right.

Figure 8: The yellow text warnings on the left and in the centre are much less legible than in the example on the right. All are packets of cigarettes from Mexico.²⁷²⁸²⁹

Relevant Link

• TPackSS: Tobacco Pack Surveillance System

Tobacco Tactics Resources

• Bangladesh Country Profile
• India Country Profile
• Lebanon Country Profile
• Philip Morris vs the Government of Uruguay
• Plain Packaging

TCRG Research

• Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh, M.H. Shahriar, M.M. Hasan, M.S. Alam et al, Tobacco Control, 2023.
• Cross-sectional online survey of the impact of new tobacco health warnings in Colombia, S. Adams, A. Clavijo, R. Tamayo et al, BMJ Open, 2022.
• Evaluating the impact of introducing standardized packaging with larger health-warning labels in England: findings from adult smokers within the EUREST-PLUS ITC Europe Surveys, S. Aleyan, P. Driezen, A. McNeill et al, European Journal of Public Health, Volume 30, Issue Supplement 3, July 2020.
• Plain packaging increases visual attention to health warnings on cigarette packs in non-smokers and weekly smokers but not daily smokers, M.R. Munafo, N. Roberts, L Bauld et al, Addiction, Volume 106, Issue 8, August 2011.