Thursday, April 14, 2016

Effectiveness of warnings on cigarette packs

First published in The Korea Herald.

As expected, South Korean tobacco-makers and retailers have expressed their opposition to the Health Ministry’s new antismoking policies, which require all firms to fix health warning illustrations on their cigarette products. However, the ministry is not being swayed by their arguments and has refused to stand down.

The new measures, which will be implemented later this year, require health warnings consisting of text and images to be printed on the top 50 percent of the front panels of all cigarette packets. In addition, retailers have to display the front panel bearing the warning graphics to customers.

The graphics have to show tobacco’s harmful effects as well as health conditions that may be triggered by heavy smoking, including heart disease, lung cancer and possible birth defects.

The tobacco lobby claims the government is interfering with their rights to product design, as almost all cigarette packs will look more or less identical.

Dismissing their arguments, the Health Ministry has said that some 80 countries overseas require cigarette products to have warning illustrations, and of them, 63.8 percent make it mandatory for the warnings to appear in the upper portion of the packs.

From an economic standpoint there are many questions that need to be asked in this tug-of-war.

Have warning graphics discouraged smokers?

Have these policies affected the revenues of tobacco-makers in countries where this policy has been implemented?

What has been the economic impact on tobacco firms?

According to a recent report by the U.S.-based nonprofit organization Campaign for Tobacco-Free Kids, despite the numerous public reports on the risks of smoking, studies show that a large number of smokers have inadequate knowledge of the health effects of smoking.

“While some smokers generally know that tobacco use is harmful, they underestimate the severity and magnitude of the health risks and tend to perceive other smokers to be at greater risk for disease than themselves,” it notes

Knowledge of the health risks of smoking is even lower among people with lower income and fewer years of education because of limited access to information about the hazards of smoking.

Therefore, health warnings on cigarette packs have been found to inform smokers about the health hazards of smoking, encourage smokers to quit and prevent nonsmokers from starting to smoke.

Studies by the International Tobacco Control Policy Evaluation Project, an international cohort study that surveys adult smokers in 19 countries, provides much of the evidence base for health warnings.

According to ITC research, adult and youth smokers report that large, comprehensive warnings reduce smoking consumption, increase motivation to quit and increase the likelihood that they will remain abstinent following an attempt to quit.

It shows graphic warnings are more effective than text-only warnings in leading people to think about quitting and deterring them from having a cigarette.

Further, ITC studies of smokers in Australia, Canada, the United Kingdom and the U.S. revealed that graphic warnings are more effective than text-only warnings at making smokers think about quitting and deterring them from having a cigarette, and that larger, pictorial warnings are associated with increased quit attempts.

Evidence from Canada, the first country to implement graphic warnings, shows that after controlling for price, graphic warnings significantly decreased the odds of being a smoker and significantly increased the odds they would try to quit.

After Singapore introduced their graphic warnings in 2004, 28 percent of smokers surveyed reported smoking fewer cigarettes because of the warnings; 14 percent of the smokers surveyed said that they made it a point to avoid smoking in front of children; 12 percent said that they avoided smoking in front of pregnant women; and 8 percent said that they smoked less at home.

Since Thailand introduced their second set of pictorial labels in 2006, 44 percent of smokers said the warnings made them “a lot” more likely to quit over the next month.

In Brazil, after the introduction of new graphic warnings in 2002, 67 percent of smokers said the new warnings made them want to quit.

Given this, the Korean Health Ministry may be right to conclude that these measures will be effective in South Korea, home to almost 10 million smokers, where an estimated 57,000 die every year due to smoking-related diseases.

According to the World Health Organization, warning labels on tobacco products constitute the most cost-effective tool for educating smokers and nonsmokers alike about the health risks of tobacco use.

“In many countries, more smokers report getting information about the health risks of smoking from warning labels than any other source except television,” it notes.

Countering the claims by tobacco-makers, it says, “For decades, the tobacco industry has taken advantage of the package as a venue for creating positive associations for their product. The use of graphic pictures is an important means of replacing those positive associations with negative associations, which is far more appropriate given the devastating impact of tobacco products on global health.”

All these arguments seem valid, and if true, the tobacco-makers will certainly see a dent in their revenues once the policy is implemented.

However, I am not really convinced that it will lead to a dramatic fall in the number of smokers in Korea.

In 2014, the National Assembly approved an 80 percent increase in the price of cigarettes, from 2,500 won ($2.17) per pack to 4,500 won, in an effort to curb smoking. The new bill took effect on Jan. 1, 2015.

While in the initial few months, there was a decline in the revenue of tobacco-makers here -- as many smokers started experimenting with e-cigarettes -- it was short-lived, and the revenues have again increased a year later. The only beneficiary has been the government, whose tax kitty has swelled.

As noted by Maastricht University researchers in a recent article in Health Psychology Review, “Scary graphic warning labels are a popular tool among policymakers, but there is no clear consensus within the scientific community regarding their efficacy.”

The researchers looked at an initial selection of 295 publications exploring “fear appeals,” including graphic warning labels, then eliminated studies that had methodological problems.

“Not only is there little evidence that could support the use of graphic warning labels, but if you combine the evidence that is available, it turns out that at best, the use of graphic warning labels only has a small effect, while in the worst case, it may even backfire,” they noted.

It remains to be seen how the policy pans out in South Korea -- with a tobacco market widely perceived to be  demand ineleastic -- but my bet is in the long run it will make little difference.