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Back of pack health warnings have little impact on teen smokers

The causal link between lung cancer and tobacco smoking has long been established. It was in the 1950s that the link was first clearly demonstrated. Since then the addictive nature of nicotine has also been shown and it is one reason why it is so difficult for smokers to stop.

Despite this knowledge it took a long time for health authorities and governments to act effectively on smoking as a killer. Today, smoking is recognised as the largest single factor in preventative illness. In the UK an estimated 102,000 people die each year from smoking-related diseases including cancers.

Most people start smoking as teenagers. I certainly recall my first tentative 'drags' on a cigarette when I was at school. In those days (oh dear such a long time ago!) we were able to buy single Woodbines at the local tobacconists. Fortunately I managed to stop smoking in my early twenties; others were not so fortunate.

Teenage smoking remains a problem. Official statistics suggest that at the age of 15 years, 11% of children in England report being regular smokers.  In recent years, girls have had consistently higher rates of smoking than boys. But clinical studies suggest the incidence of teenage smoking is much higher than suggested studies relying on self-reporting.

In 2008 the UK became the third European Union country to require pictorial health warnings to be carried on the back of cigarette packs. But does it work as a deterrent?

A new study published today online in Tobacco Control suggests that back of pack picture or text warnings depicting the dangers of smoking have little impact on teenage smokers, particularly those who smoke regularly.

Pictorial warnings work better than text alone, but if positioned on the back of the pack they are less visible and less effective, say the researchers.

In only five out of the 60 countries worldwide do these pictorial warnings cover more than 75% of the main surface areas of a pack. Furthermore, no European country including the UK has adopted the World Health Organization standard of warnings covering half the surface area. Article 11 of the Framework Convention on Tobacco Control (FCTC) provides that package health warnings must be at least 30% – and should be at least 50% – of the package’s front and back (on average). The use of pictures is optional.

The current study published today looked at the responses of more than a thousand 11 to 16 year olds in the UK, in two waves of the Youth Tobacco Policy Survey in 2008 (1401) and 2011 (1373).

The same text warnings appeared on the front and back of packs at both surveys, with the only difference being the display of images on the back of packs to support the text warnings in 2011.

The teens were quizzed about the visibility and impact of the warnings; how well they served as visual cues; how easy they were to understand and believe; and how persuasive they were. Their responses were scored on a sliding scale from 1 to 5.

Most of the respondents in both waves (68-75%) had never smoked; 17-22% had experimented with cigarettes; and around one in 10 were already regular smokers, defined as smoking at least one cigarette every week.

Half the respondents in both waves said they had ‘often’ or ‘very often’ noticed the warnings, and around one in five had very often read or looked closely at them. But the percentage of regular smokers who noticed them fell from 77% in 2008 to 66% in 2011.

Overall, only one in 10 teens said they thought about the warnings when the pack was not in sight, although those who had never smoked were significantly more likely to think about warnings ‘often’ or ‘very often.’

At both time points, most (85%+) teens found the warnings credible, but in 2011 those who had never smoked were less likely to find them easy to understand, while experimental smokers were more likely to find them truthful and believable.

And while the proportion of teens who thought the warnings were capable of putting them off smoking and make them less likely to smoke increased between 2008 and 2011, this only applied to those who had never smoked and to experimental smokers. There was no change among the regular smokers.

Recall of text warnings on the pack front fell between 2008 and 2011, from 58% to 47% (Smoking Kills) and from 41% to 25% (Smoking seriously harms you and others around you), while recall of three images on the back of packs, depicting diseased lungs, rotten teeth and neck cancer, all increased.

However, recall of the other back of pack images remained below 10%, and the three text warnings on the back of packs with no supporting images were recalled by less than 1% at either time point.

The proportion of teens who said they hid the cigarette pack from others increased significantly between 2008 and 2011, but there was no increase in other avoidant behaviours. And among regular smokers, the proportion who said that the warnings stopped them from having a cigarette fell from 32% to 23%.

“As warnings need to be salient to be effective, positioning pictorial warnings only on the less visible reverse panel limits their impact,” write the authors. “While recall was high at both waves for pack-front warnings, it was low (below 10%) for the pictorial warnings on the pack reverse, fear-appeal pictures aside,” they add.

The fact that the UK has used the same pictures since 2008 may also have increased the “wear out” factor, particularly for regular smokers, say the authors.

“Positioning pictorial warnings only on the back of packs may have had a deterrent effect on never and experimental smokers, but for most measures no significant differences were observed. The impact on regular smokers was negligible,” they conclude.

If warnings are ever to work then they have to be more prominent. Regular teenage smokers may be harder to crack. We need a better understanding of what drives them to smoking in the first instance and how best they can be persuaded to stop.

There is much to suggest that teenage smoking is imitative or seen to be 'cool'. Smoking is more prevalent amongst those whose parents also smoke.  Smoking can also be a form of rebellion and is heavily influenced by glamorous advertising. We need to address the socio-psychology of why teenagers smoke.

Cigarette manufacturers produce a product that ruins health and kills.  Smoking kills should be the only words appearing on any packaging.   But more important, governments should not bend to the will of powerful lobbyists for the tobacco industry. What happened to the call for plain packaging?

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