Well-documented evidence shows that graphic health warning labels on tobacco packaging and hard-hitting mass media campaigns reduce tobacco use. According to the WHO report on the global tobacco epidemic 2011 (1), effective warning labels on tobacco packaging serve several purposes, including disrupting the marketing value of the packages. Because traditional avenues for marketing tobacco products have become increasingly restricted due to wider adoption of bans on tobacco advertising, promotion and sponsorship, the tobacco industry has become increasingly more reliant on cigarette packaging as a primary marketing vehicle. Warning labels reduce the marketing effect of tobacco product packaging, making it more difficult for tobacco companies to reinforce brand awareness (1).
Moreover, the WHO report on the global tobacco epidemic 2011 describes how graphic health warnings raise the awareness of many people who are unaware of the deadly impact of tobacco use; have greater impact on health and are more powerful than just text warnings; can promote quit line numbers to the public; have greater impact on youth and that youth respond to their messages; cost the government nothing as they are paid for by the tobacco industry, while the health impact reduces government spending on responding to tobacco use consequences; can be made stronger in many countries, either through larger graphics or through implementing plain packaging; and will be opposed by the tobacco industry, but that all their arguments can be easily countered (1).
In addition, the guidelines for implementation of Article 11 (packaging and labelling of tobacco products) of the WHO Framework Convention on Tobacco Control (FCTC) (2) note that globally, many people are not fully aware of, misunderstand or underestimate the risks for morbidity and premature mortality due to tobacco use and exposure to tobacco smoke. Well-designed health warnings and messages on tobacco product packages have been shown to be cost-effective means to increase public awareness of the health effects of tobacco use and to be effective in reducing tobacco consumption.
Against this background, a regional intercountry meeting was held in Cairo, Egypt, 26–28 July 2016 (3), to bring together experts with experience in this area from the Region to discuss the way forward to protect their populations through the medium of large graphic health warnings on tobacco products. The meeting also sought to explore how to empower governments to face pressure from the tobacco industry, by taking a whole-government approach in order to increase the effectiveness of implementing large graphic health warnings. Specifically, the meeting brought together, for the first time, colleagues from ministries of health and from the specification committees that are usually national partners in implementing graphic health warnings. This presented a unique opportunity to discuss the status of graphic health warnings at a national level and examine ways forward.
However, in the WHO Eastern Mediterranean Region (EMR), many countries are facing challenges as they move to enlarge their graphic health warnings on tobacco packs; primarily the effort of the tobacco industry to defeat, delay and/or compromise such proposals. Despite these aggressive tactics, the well-documented impact of graphic warnings on reducing tobacco prevalence has led some countries to move beyond classic graphic health warnings to implement total plain packaging. This phenomenon began in Australia, but now more countries are joining in including France, Ireland, New Zealand and the United Kingdom. Moreover, other countries have moved towards implementing larger warnings that cover more than 50% of the principal display area (1).
The WHO Eastern Mediterranean Region now has 12 countries implementing graphic health warnings. The last major changes in the Region were in 2012, when six Gulf Cooperation Council (GCC) countries adopted graphic health warnings at 50% of the package front and back, and in 2014, when Yemen adopted graphic health warnings with the same GCC specifications (4). The other Member States’ status are: Afghanistan adopting legislation for implementing graphic health warnings at 50%; Egypt has implemented graphic health warnings at 50% since 2014; Iraq adopting legislation for implementing graphic health warnings at 40%; the Islamic Republic of Iran has required graphic health warnings at 50% since 2009; Pakistan has implemented graphic health warnings at 40% since 2010; Palestine proposing a new by-law that includes the implementation of graphic health warnings at 20%; and Sudan adopting one of the few examples globally of sub-regional legislation on implementing graphic health warnings in Khartoum State at 30% (implementation started in 2016) (4). Yet, the tobacco industry is still lobbying hard to stop any developments in the area of graphic health warnings in the Region (1).
Taking these historical developments in mind, participants at the regional intercountry meeting summarized discussions with the following recommendations to support progress in reducing tobacco advertising and subsequent use:
Countries without graphic health warnings should consider changing their policies to implement graphic health warnings covering 50% or more of the principal surfaces of the pack.
Countries implementing graphic health warnings should review their policies in order to achieve the highest level of the policy, including standardized packaging.
In collaboration with WHO country offices, countries should request WHO and WHO FCTC Secretariat technical support for the development and implementation of graphic health warnings.
Based on the country-specific recommendations, steps should be taken to fully implement the agreed activities.
World Health Organization (WHO)
WHO FCTC Secretariat and WHO Tobacco Free Initiative should organize an experience-sharing session on large graphic health warnings and standardized packaging to share the experience of countries already implementing them.
WHO Regional Office for Africa should coordinate focused sessions on graphic health warnings and standardized packaging during the forthcoming World Conference on Tobacco or Health to be held in South Africa in 2017.
WHO Regional Office for the Eastern Mediterranean (WHO/EMRO) should release, as soon as possible, the library of graphic health warnings for all countries to use.
WHO regional offices for Africa and EMRO should:
Engage with regional and subregional economic blocks on the issue of graphic health warnings and standardized packaging. These include but are not limited to: African Small Island Developing States (SIDS), Central African Economic and Monetary Community (CEMAC), East African Community (EAC), Economic Community of West African States (ECOWAS), Organization of Islamic Cooperation (OIC), Southern African Development Community (SADC) and West African Economic and Monetary Union (WAEMU).
Prepare evidence on the effectiveness of large (above 50% of the principal display area) graphic health warnings in the form of a factsheet or information package, including on tobacco industry interference in the implementation of Article 11 of the WHO FCTC.
Support countries in documenting tobacco industry litigation-related activities at country level.
Provide technical support to countries wanting to advance graphic health warning policies, including standardized packaging, upon request.
Keep countries updated on international best practices and developments through communicating the information to high-level decision-makers, tobacco control focal points and WHO country offices.
Support countries to raise public awareness on the importance of the implementation of Article 11 and its guidelines, including graphic health warnings and standardized packaging.
Document and disseminate country experiences in the implementation of Article 11 in collaboration with ministries of health.
- WHO report on the global tobacco epidemic 2011. Geneva: World Health Organization; 2011 (http://www.who.int/tobacco/global_report/2011/en/).
- Article 11 of the WHO framework convention on tobacco control – packaging and labelling of tobacco products. Geneva: World Health Organization; 2003 (http://www.who.int/tobacco/industry/product_regulation/art_11_fctc/en/).
- Regional intercountry meeting on the implementation of pictorial graphic health warnings and plain packaging on tobacco products. WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt 26–28 July 2016.
- Package health warnings: international status report (fourth edition). Toronto: Canadian Cancer Society; September 2014 (http://global.tobaccofreekids.org/files/pdfs/en/WL_status_report_en.pdf).
1 This report is extracted from the Summary report on the Regional intercountry meeting on the implementation of pictorial graphic health warnings and plain packaging on tobacco products, Cairo, Egypt 26–28 July 2016 (http://applications.emro.who.int/docs/IC_Meet_Rep_2016_EN_18980.pdf)