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Vital Stories

A Picture of Health: How Graphic Pack Warning Labels Stem Tobacco Use in Africa

Vital Strategies

Q & A with Irina Morozova, technical advisor of the tobacco control program at Vital Strategies 

Tobacco kills 8 million people every year and is linked to the onset of the four most common noncommunicable diseases: cancer, heart disease, diabetes and lung disease. A major force behind today’s global tobacco epidemic is the industry’s marketing and advertisement of tobacco products, especially to young people, women and people living in resource-constrained countries.   

“Chad used tested graphic pack warning labels on cigarette packages from 2017 to 2019 including  an image of Idrissa Diallo, who was featured in a testimonial PSA. These were some of the very first images we used. According to consumer testimonials, these images were striking. For example we have heavy smokers in government who have smoked for over 20 years, but because of these graphic pack warning labels, they have quit permanently. In terms of impact, our Global Youth Tobacco Survey results show a significant decrease in the prevalence of smoking after the implementation of graphic pack warning labels.”

Dr Nenodji Mbairo, Coordinator of the national tobacco control programme at the Ministry of Public Health, Chad.

One way to counter the tobacco industry’s efforts to hook new tobacco users: Graphic pack warning labels that show the harms of tobacco use. Hard-hitting graphic pack warnings are a proven way to warn consumers of the dangers of smoking. They can serve as an important communication channel to educate not only smokers but also those around them. And they cost policymakers nothing. It’s a win-win. 

Vital Strategies has worked alongside partners and ministries of health to implement graphic pack warning labels across the globe. Irina Morozova, a technical advisor for the tobacco control program, explains more about Vital’s work supporting efforts to implement strong graphic pack warning labels in Africa:   


We know graphic warning labels are important, but how exactly do they alert consumers of the dangers of tobacco use? 

Every time a person goes to buy a pack of cigarettes, they are reminded—at the point of decision-making—of tobacco’s health harms. Graphic warning labels use hard-hitting, real-life visuals to reinforce the extent of tobacco-related diseases, including lung diseases and cancer.  

 

Even though the WHO Framework Convention on Tobacco Control (FCTC)—the first international public health treaty—recommends all governments warn people of the dangers of smoking, only 101 of the 182 countries that have ratified the FCTC have evidence-based graphic warning labels.   

 

An example of a graphic warning label from the United Kingdom

Message testing is a scientific method designed to get insight from target audiences on whether communication concepts are effective and resonate with audiences. 

How has Vital Strategies supported efforts to implement graphic pack warning labels in the African region? 

Most of the countries in Africa have ratified the FCTC but only 16 have implemented pictorial health warnings. With 77 million adult smokers in Africa and tobacco use growing in the region, especially among young girls, implementing graphic pack warning labels can stem tobacco consumption and deter initiation.  

 

One of our initiatives to support African countries to implement graphic pack warning labels was in partnership with the WHO FCTC Secretariat. We were asked to design high impact graphic pack warning labels for countries in the sub-Saharan region. We noticed that most graphic warning labels did not have images that pictured Black people. The most effective graphic warning labels are regionally and culturally appropriate. Taking that into account, we created a database of message-tested warning labels that are available and free to use.   

What did the message testing process look like? What were the results?

For our message testing work, we consulted the WHO Global Report on Mortality Attributable to Tobacco to develop a list of 24 messages that addressed the dangers of smoking and secondhand smoke and the addictive nature of tobacco. Our team sourced illustrative, diverse, culturally appropriate images depicting the real-life health harms of tobacco. Many of the images were taken in hospitals throughout the region or sourced from medical archives. We also borrowed images from past tobacco control public service announcements (PSAs) with the permission of the owners.  

 

The graphic warning labels were then tested with 1,200 people (both smokers and nonsmokers) in urban and periurban settings in  Senegal and Botswana using street-intercept surveys. Through a qualitative methodology of rating forms and group discussions, we found that simple and clear images depicting the visible damage of tobacco were the most effective.  

Street-intercept surveys are conducted with consumers on the street in key locations. 

How can countries access tested materials?

The 50 images that were deemed most effective at highlighting the harms of tobacco were gathered in a World Health Organization database, available for any country to use and implement on tobacco packages. Following our work, 11 countries in Africa implemented graphic warning labels using our findings and images.  

 

Newly published research found that the introduction and implementation of graphic pack warning labels in Kenya substantially increased health warning effectiveness compared to text-only warning labels. The study found 79.4% of Kenyan smokers were more likely to notice the graphic pack warnings “often or very often” compared to 60% of the text-only warnings, and 27.8% of Kenyan smokers were more likely to forgo a cigarette due to the graphic pack warning labels compared to 18.5% of smokers viewing the text-only warnings. Kenya’s example offers the latest evidence that graphic pack warning labels work. With a database of tried and tested images and research all countries should follow suit.  

 

Have you paired other communication approaches with graphic pack warning labels to communicate the harms of tobacco? 

Yes!  We’re also using communication campaigns that feature the pack warning images to build public support. Communication campaigns along with graphic warning labels can reach wider audiences and motivate smokers and nonsmokers alike to say no to tobacco. A few examples include: 

 

  • In Chad, Vital Strategies partnered with the Ministry of Health to create and launch the country’s first tobacco control campaign. The campaign featured a public service announcement (PSA) “Idrissa” which reinforced the use and benefit of graphic pack warning labels as they were introduced in the country. “Idrissa” was broadcast on national television and radio stations over eight weeks and tells the story of Idrissa Diallo, a man from Guinea-Bissau who developed advanced mouth cancer after years of smoking and tragically passed away, devasting his entire family. Idrissa’s image now appears on graphic pack warning labels in Chad. 
  • In Viet Nam, we shared a communication campaign “Tobacco Is Eating Your Baby Alive” to display new graphic health warnings that were implemented in 2013. The PSA highlights how graphic warning labels on cigarette packs can illustrate the serious health effects of tobacco on children. 
  • In Bangladesh, we partnered with the state minister for health and family welfare to produce a powerful national mass media campaign, “Live Long, Don’t Smoke,” showing the deadly harms of tobacco and promoting the importance of warning labels on tobacco packs  
“Idrissa” tells the story of Idrissa Diallo who developed mouth  cancer after smoking.  

“Tobacco Is Eating Your Baby Alive” featured new graphic health warning images on cigarette packs in Vietnam. 
“Live Long, Don’t Smoke depicts the deadly effects of tobacco use.  

As you mentioned, only 101 countries have implemented strong evidence-based graphic pack warning labels. Do you have anything to say to encourage more governments to adopt graphic labels? 

The saying “a picture is worth a thousand words” is true. In the case of tobacco control, graphic pack warning labels are an effective tool for communicating the health risks of smoking, especially to people with low literacy rates. In some countries and regions, where there is a lack of funding for interventions such as mass media campaigns on tobacco use, graphic warning pack labels are an effective measure to reduce consumption. Listing quitline numbers on tobacco packaging is also a great way to drive smokers to get help to quit.  

 

Governments should implement graphic warning labels immediately. Graphic warning labels are proven to work, its implementation can also catalyze support for other tobacco control interventions such as smoke-free places or increased tobacco taxes. In addition to graphic pack warning labels on cigarette pack, newer products such as e-cigarettes, heated tobacco products and smokeless tobacco (which are on the rise, especially among youth) should be regulated with  graphic warning labels and marketing restrictions. 

Access the graphic pack warning label images and follow us on Twitter at @VitalStrat.