Will Graphic Images on Cigarette Health Warnings Work?

BlogHer Original Post

The carnival of horrors is coming to the United States at last and all smokers are invited.

On Wednesday, health officials unveiled their plans to replace the text-only warnings on cigarette packs with graphic image warnings, including pictures of diseased organs and corpses.

The Food and Drug Administration, exercising new powers approved by Congress last year, will select nine of the 36 proposed new images, after hosting a lively round of public discourse and doing some reading of the available scientific literature. Come October 22, 2012, any cigarette makers that don't have new warnings on their packaging will be restricted from selling their brands in the U.S.

"When the rule takes effect, the health consequences of smoking will be obvious every time someone picks up a pack of cigarettes," FDA Commissioner Margaret A. Hamburg said.

The U.S. is playing catch-up on its anti-smoking efforts, mostly untouched since 1984, when Congress enacted legislation requiring new warning labels for cigarettes. Some 30 countries already require graphic imagery on cigarette packaging, most notoriously among which is Canada, the first country to require these warnings a decade ago.

But as The Washington Post reported, many health activists find the measure inadequate in a country where one in five adults and teens smoke despite the fact that smoking is the leading cause of premature and preventable death.

As a smoker, I have encountered these warnings, usually when I perceived a change in the wording or when, while traveling in a different country, I encountered the warning in another language. I even collected the warnings, as a sort of travel memento. As far as contemplating my health, they seemed to have no effect.

It's possible that the drastic change from text to imagery will attract some attention, but when I initially contemplated the notion, I wasn't moved.

It reminded me of an incident that occurred at the premiere of National Geographic's Great Migarations in Beverly Hills a few weeks ago with my friend Jason Goldman, who blogged about it. The audience responded with loud dismay when the wildebeest herd lost a calf to hungry crocodiles during their dash across the Mara River. But a few minutes later, these same people stampeded over one another to gorge themselves on the sandwiches, pizza bites and sushi that had been made available at the reception.

There seems to be a disconnect between the world and ourselves, a strange sort of denial. Though we eat meat and fish, we are not predators like the crocodile. Though we run over one another eagerly to get at the last spicy tuna roll, we are not opportunistic eaters. Somehow, we're different.

Somehow, I'm different than the number on that billboard I see every time I take Santa Monica to get home. The number that tallies all the smoking deaths this year.

I think text ads, in their careful and inoffensive manner, do little to shake the denial. Or disconnect. Call it what you like.

Smoking may cause cancer.

I typed that with a cigarette resting between my index and middle finger. Would it give me pause if the package said “Smoking will kill you” instead? Or if the cigarette itself read “I am killing you” or “You're consuming your own life?” Or would that just make cigarettes cool again, somehow fuel a juvenile sense that I'm a consummate contrarian, subversive and invincible, sucking on death?

What about a graphic image? Would that help shake the denial?

I turned my attention to the available scientific literature addressing the use of images in cigarette health warnings.

A study by Michelle O’Hegarty and her team published in The American Journal of Preventive Medicine in 2006, which surveyed a panel of 763 smokers and former smokers between the ages of 18 and 24, found that warnings that made use of text and graphics were more effective in terms of prevention, motivation to quit, motivation not to start smoking, and heightened concern about health effects. Another study, this one lead by Constantine I. Vardavas and published in The European Journal of Public Health last year, found that the 574 teens that were surveyed considered graphic images on warning labels more effective than text-only warnings.

The O'Hegarty study made note of the elaboration likelihood model in their discussion of the results:

If the message is of importance to the receiver, then the central route to persuasion is most effective. However, if the receiver is not interested in the message or cannot process the information, the peripheral route will provide the way to produce attitude change. In the case of warning labels, the use of a peripheral message, with a visual image, may provide a means for gaining audience attention for quitting smoking among smokers who are not interested in quitting.

The discussion also touched on the over-exposure factor: continued exposure to both types of warnings will result in a decrease in effect. This was echoed in the Vardavas study:

When the current text-only EU warning labels were introduced, research indicated their significant impact of cessation attempts and the inclination to purchase cigarettes, as they were more noticeable than the one it replaced and had the strength to motivate smokers to quit. Over the years though, and especially among Southern European countries the effectiveness of the current EU text-only warnings has reduced.

The latter study mentioned that research seems to indicate that larger, more vivid warnings maintain their effectiveness over a longer time than text-only warnings. In Canada, which has been using graphic warnings since 2000, impact remained high even four years after their implementation.

All studies I surveyed seem to agree that the images used will need to be changed with some frequency to prevent burn out among consumers.

Here's what I want to know: what happens when the graphic imagery we're using is no longer enough to shake the denial? When the tag on the toe suggesting a dead body isn't enough to give us some pause? Will we one day be so desensitized to these images we'll need more and more graphic ones to get the message across?

Is there a better way? How can health activists better connect the dots for smokers? How can we make the risks accessible in a real way?

I don't know. But I'll tell you this: having pored over all the available literature and statistics relating to smoking in order to write this story, I'm second guessing lighting that congratulatory cigarette now that I've wrapped this article.

Maybe that's what we smokers need: to put away the defensive snarking and simmer on data for a day or two as we attempt some level of objectivity.

Special thanks to Jason Goldman for his help in rounding up the available scientific literature on the topic.

AV Flox is the editor of Sex and the 405 -- what your newspaper would look like if it had a sex section.


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