A sample of the 36 warnings being considered by the Food and Drug Administration. Nine will be chosen. A federal law requires that the warnings appear on the upper portion of the front and rear panels of each cigarette package and make up at least the top 50% of these panels. Images courtesy of FDA

Will graphic pictures influence severely addicted smokers?

It all depends on how the government links the images and text warnings, says the chair of the AAFP's Tobacco Cessation Advisory Committee.

By Christine S. Moyer — Posted Nov. 22, 2010

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Family physician Tom Houston, MD, has seen patients so addicted to nicotine that they smoke cigarettes through their tracheotomy holes.

"People don't understand how addictive it can be," he said.

The Columbus, Ohio, doctor is optimistic that the new text and graphic image health warnings set to appear on cigarette packages in 2012 will make an impact on smokers and those who are considering starting the habit. But he said the question is whether the effect will be great enough to prompt even the most addicted smokers to quit.

"It depends on how [the government] ties together the pictures and text warnings," said Dr. Houston, chair of the Tobacco Cessation Advisory Committee for the American Academy of Family Physicians. "But it's a great improvement from what's going on now. Research shows that the current warnings are old; people don't pay attention to them. They have lost their impact and meaning."

The Dept. of Health and Human Services on Nov. 10 unveiled the federal government's latest initiative to cut tobacco use. The strategy features new, bolder health warnings on cigarette packages and in cigarette advertisements. These will update the text warning that has been in place for about 25 years.

The effort is part of the Family Smoking Prevention and Tobacco Control Act, which was approved by President Obama and became law in June 2009. The legislation calls for nine new larger text warning statements and color graphic images depicting the negative health consequences of smoking on cigarette packages and in advertisements.

Thirty-six images, accompanied by text, are being considered. They include a body in a morgue, a man in a casket, diseased lungs and a woman blowing smoke on a baby's face.

The warning label will fill at least the top half of the front and back of cigarette packages. In cigarette advertisements, the warning will be positioned in the upper right corner and fill at least 20% of the total space. For advertisements with a surface area less than 12 square inches, a color graphic, such as a cigarette with a line through it, will accompany the warning statement.

The public can comment on the proposed images through Jan. 9, 2011. The Food and Drug Administration will review the feedback and relevant data before selecting the nine graphic and textual warnings by June 22, 2011.

In September 2012, cigarette manufacturers will have to start producing their products with the new warning. That month, warning requirements for cigarette advertisements will take effect. By October 2012, all cigarettes on the market will be required to have the new labeling.

"We want to make sure that anyone who's considering smoking fully appreciates the consequences of cigarette use," said FDA Commissioner Margaret A. Hamburg, MD. "Tobacco use is still the No. 1 cause of premature death in America. ... And this is the preventable tragedy we're trying to address."

Although the nation's smoking rate has been declining for decades, it has stalled recently, according to the Centers for Disease Control and Prevention. In 2009, one in five adults 18 and older smoked cigarettes. Though that is an improvement from 1978, when about one in three adults smoked, the rate has remained stable for the past five years.

An estimated 46.6 million U.S. adults (21%) smoke, according to the CDC's Nov. 18 Morbidity and Mortality Weekly Report. The habit causes about 443,000 deaths each year due to firsthand and secondhand smoke.

"From a medical point of view, it's critically important that we do everything we can to reduce the number of people who smoke," said Len Lichtenfeld, MD, deputy chief medical officer for the national office of the American Cancer Society. "The [warning] labels are a step in the right direction, but they're only a step, and they're not the entire effort."

Other federal measures to curb tobacco use include restricting the terms "light," "low" and "mild" on cigarette packages and implementing restrictions on the sale and distribution of cigarettes and smokeless tobacco products to youths.

Several organizations support the proposed label warnings, including the American Assn. for Cancer Research and the American Cancer Society Cancer Action Network.

Sen. Tom Harkin (D, Iowa) praised the strategy, saying the warnings "will ensure that Americans are confronted with the brutal realities of tobacco use every time they pick up a cigarette package." Harkin is chair of the Senate Committee on Health, Education, Labor and Pensions.

The American Medical Association supports working toward more explicit and effective health warnings regarding tobacco products, including requirements to list the ingredients in such items sold in the U.S. The AMA also encourages regulations that require picture-based warning labels on tobacco products produced in, sold in or exported from the U.S.

Tobacco company Philip Morris USA issued a statement saying it supports several of the government's tobacco control initiatives, including giving the FDA regulatory authority over tobacco products and stopping the illegal sale of such items to youths. The statement did not address the new warning labels.

Dr. Houston said the proposed image of a man smoking through his tracheotomy hole, accompanied by the warning "Cigarettes are addictive," is among the most powerful and could impact consumers. But he thinks the cautionary labels need to appear on cigarette packages earlier than October 2012. He plans to raise this concern when he submits his comment to the FDA.

He said the government should continue supporting state and local tobacco cessation efforts as governing bodies are forced to tighten their budgets. "States will be looking to cut programs they consider expendable and, unfortunately, tobacco cessation will be some of those [cuts] that occur first. It's already happening," Dr. Houston said. "If HHS can help the states preserve their tobacco [cessation] programs, that would be a wonderful thing."

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External links

Proposed cigarette warning labels, Food and Drug Administration (link)

"Great American Smokeout -- November 18, 2010," Morbidity and Mortality Weekly Report, Nov. 12 (link)

"Vital Signs: Current Cigarette Smoking Among Adults Aged 18 years and older -- United States, 2009," Morbidity and Mortality Weekly Report, Sept. 10 (link)

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