This article is written by Shubham Sharma & Tanya Singh, students of Lloyd Law College, Delhi (NCR).

Outline

The health warning’s textual and pictorial components cover 85 percent of the front and reverse flaps of the tobacco product package, with 25 percent assigned to text and 60 percent to picture. For the first 12 month rotation period, there is one photo, and for the second 12 month rotation period, there is another picture. Color resolution and intensity are likewise governed by the guidelines. 

The warning text must be displayed in white font on a red background, and the information about the quit-line must be written in white font on a black background. The legislation requires a pictorial depiction of the harmful effects of tobacco consumption on health above the text.

The health warning must be displayed on the package’s top edge. The warning should have a width of at least 3.5 cm and a height of at least 4 cm. In terms of warning size, area, and rotation, these provisions comply with FCTC Art. 11 and the FCTC Art. 11 Guidelines.

Prologue

Tobacco is a severe concern to global health, killing roughly 6 million people each year and costing the global economy hundreds of billions of dollars in extra healthcare expenditure and lost productivity. Various cardiovascular and respiratory disorders, oral cancer and its recurrence, adult periodontal illnesses, birth defects, retards healing following oral surgical and accidental wounds, and accelerates periodontal degeneration in diabetics are all risk factors for both smoked and smokeless forms. Cigarettes are responsible for roughly 1.5 million lung cancer deaths each year, a statistic that might increase to roughly 2 million by the 2020s or 2030s, even if consumption rates reduce in the interim.

Many individuals around the world are unaware of, misunderstand, or underestimate the risk of health and early death caused by tobacco use and tobacco smoke exposure. While tobacco product packaging is an essential component of marketing attempts to encourage tobacco use, authorities can utilize it to inform consumers about the health risks. When compared to other anti-tobacco messaging, such as mass media campaigns, messages on these packs would generate significantly more exposure.

The evolution of health warning labels on tobacco products, WHO Framework Convention on Tobacco Control (WHO FCTC) guidelines and their implementation, the international and Indian scenario, and future perspectives are all addressed in this review.

Meaning & Composition

Tobacco is a plant that grows in warm areas and is green and leafy. Tobacco combustion produces around 4000 compounds. The gas and particle phases of smoke can be separated. Carbon monoxide, carbon dioxide, nitrogen oxides, ammonia, hydrogen cyanide, and volatile chemicals such as nitrosamines, sulfur-containing compounds, hydrocarbons, alcohols, aldehydes, and ketones are all key components of the gaseous phase. Particulate phase consists primarily of tar, formaldehyde, and cyanide. Tar is the compound in tobacco that remains after moisture and nicotine have been removed, and it is composed of carcinogenic polycyclic aromatic hydrocarbons. Nicotine concentration in tobacco can range from 0.2 percent to 5%.

Nicotine is the most prevalent of the tobacco leaf’s volatile alkaloids. When exposed to the air, it turns brown and takes on the odour of tobacco. It is a colourless, volatile liquid alkaloid present in smoking and smokeless tobacco. The alkaloid is water soluble and produces salts in the presence of water. It’s the chemical in tobacco that makes it addictive or habit-forming. When nicotine enters the bloodstream, the body craves more. Nicotine is a stimulant that causes the neurological system to speed up, the heart to beat quicker, and the blood pressure to rise. As a consequence, nicotine turns tobacco into a narcotic.

History of Tobacco 

Tobacco use can be traced back to 600 to 900 A.D. Before Europeans took over, American Indians were the first to plant tobacco. Tobacco was smoked by Native Americans for religious and medical purposes, but not on a regular basis. Tobacco was grown as a commercial plant by the settlers of the first American colony in 1612 because it became their major source of income. People began smoking tobacco in the 1800s, either in a pipe, hand-rolled cigarettes, or cigars, or in chewable form. Toward the end of the nineteenth century, mechanization and mass marketing spread the cigarette habit. Washington Duke of North Carolina created the first commercial cigarette in 1865.

Tobacco and Health Warning Labels

Since their introduction in the United States in 1966, Health Warning Labels have spread over the world. Since then, Health Warning Labels have undergone numerous alterations through time. Health Warning Labels come in five generations. The sections that follow discuss these generations in terms of HWL evolution from text messages to pictorial warnings with graphic pictures that offer strong and precise messages.

First-generation Health Warning Labels: Vague health message on the side of the pack

In the United States, the first legislation requiring health warning labels was introduced in 1957. Following the US surgeon general’s report on smoking and health in 1964, the US Federal Trade Commission (FTC) proposed that Health Warning Labels be printed on cigarette products.

The Public Health Cigarette Smoking Act of 1969 made it illegal to advertise cigarettes on television or radio and required each cigarette box to bear the warning label, Warning: The Surgeon General has determined that cigarette smoking is harmful to your health. In 1971, the United Kingdom became the first government to enter into a voluntary agreement with the tobacco industry to include the first-generation HWL; cigarettes can damage your health, on the package sides.

Second-generation HWL: Specific health message on the pack side

Health Warning Labels from the second generation were more powerful and specific. In 1969, Iceland became the second country to adopt Health Warning Labels with a clear health message: “Cigarette smoking may cause lung cancer and heart disease.” The abrasive tone was retained. However, the tobacco business in Iceland convinced the parliament to repeal the Health Warning Labels in 1971.

Third-generation Health Warning Labels: Specific health message on the front of the pack 

Norway was the first country to use third-generation Health Warning Labels, which were printed on the front of the package which included a specific warning. Because of tobacco industry opposition, a 1975 statute mandated Health Warning Labels to appear on the pack side. All Gulf Cooperation Council countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) passed a resolution permitting Health Warning Labels on the pack front in 1987. The Middle East Tobacco Association (META), which represents the major international cigarette manufacturers in the Gulf, launched “intensive lobbying efforts” in 1988, which resulted in all countries except Saudi Arabia moving the warning to the side panel, making Saudi Arabia the first country to require a clear health message on the front of the pack (without rotation).

Fourth-generation Health Warning Labels: Rotating messages on the front of the pack

The National Swedish Board of Health and Welfare proposed in 1976 that Health Warning Labels covering 20% of the front of cigarette packs be rotated. Despite criticism from the sector, Sweden implemented rotational Health Warning Labels. The tobacco industry, on the other hand, was able to utilize Iceland’s withdrawal from mandatory Health Warning Labels to successfully obstruct a US Senate attempt to impose rotational Health Warning Labels in 1978. On the pack front, rotating Health Warning Labels were introduced in Ireland (1979), Iceland (1985), Australia (1987), Cyprus (1988) and New Zealand (1988).

Fifth-generation Health Warning Labels: Graphic images 

In 1985, Iceland passed the Tobacco Act, which mandated Graphic Health Warning Labels (GHealth Warning Labels). Fifth-generation GHealth Warning Labels were added to the Swedish Tobacco Act in 1989, covering about 70% of the pack front, featuring skull and crossbones, crosses, and cancer symbols. During the 1990s, government health agencies, non-governmental organizations, and health experts in Canada began a push to increase the size of warning labels and feature strong pictures showing the harm caused by tobacco.

Canada was the first country to use graphic photos in 2001. While in India, the business fought against the usage of the skull and crossbones sign, claiming that it would offend religious groups. Health Warning Labels were introduced in 49 countries as of 2012.

Who framework Convention on Tobacco Control?

In May, 1996, member states of the World Health Organization (WHO) joined hands to create a “Framework Convention on Tobacco Control” (FCTC). In 1999, an intergovernmental negotiating group comprising of all WHO member states was formed, and the WHO FCTC treaty was adopted in 2003.

Article 11 of the FCTC deals with the packaging and labeling of tobacco products. The purpose of the guidelines under Article 11 is to help Parties in meeting their commitments and to suggest measures that they can take to improve the effectiveness of their packaging and labeling measures. Article 11 enables each Party to develop and implement effective packaging and labeling requirements within three years of the Convention’s entrance into force for that Party.

Further, it proposes comprehensive ban actions for cigarette packaging, sales promotion, and support, as well as improved health warning labels based on each country’s socio cultural context and smoking characteristics.  

Global Progress Report 2014 (Implementation of FCTC Article 11) 

This report provides a global overview of the Convention’s implementation status, and a list of notable accomplishments, innovative approaches, and practice guidelines adopted by the parties to comply with the Convention’s requirements.

Article 11 was found to be in third place in the total analysis, with a 70 percent average adoption rate. In 90 percent of cases, health warnings are followed, according to the research. For other defining features of warnings, there is an increase in compliance in 2014 as compared to 2012.

Several Parties, including the European Union, Fiji, Mauritius, Nepal, Sri Lanka, Thailand, and Uruguay, have enacted legislation or implemented big pictorial warnings that cover more than 60% of the main display areas. A few parties, including Brunei Darussalam, Ecuador, and Panama, have reported the adoption of a fresh round of pictorial warnings.

Indian Scenario

India is the world’s third-largest tobacco producer. Tobacco was first introduced in AD 1600 by Portuguese traders. Despite the fact that the Indian school of Ayurveda has never publicly approved the use of tobacco for medicinal purposes, the idea that smokeless tobacco has a preventive effect on teeth and is a pain reliever is widespread in rural India. The use of tobacco products as a dentifrice among adolescents in India was recently revealed, demonstrating the persistence of the myth.

Tobacco usage kills 8-9 lakh people in India per year, accounting for 7% of all fatalities in people aged 30 and up. Tobacco use has been linked to heart disease, lung issues, lower respiratory tract infections, and the severity of asthma attacks. Tobacco use is responsible for over 50% of malignancies in men and 25% of cancers in women, as well as more than 80% of all oral cancers. 

Law Governing Tobacco Consumption and Distribution in India

According to Article 47 of the Constitution, “the state shall endeavor to bring about the ban of the consumption of intoxicating drinks, tobacco, and medications that are harmful to health, except for medicinal purposes.”

The Cigarettes Act of 1975 was enacted by the Indian government with the goal of restricting tobacco trade and commerce, as well as the production, supply, and distribution of cigarettes. Section 2(m) and Section 3 of the Cigarettes Act, 1975, mandated the first statutory warning: “Cigarette smoking is harmful to one’s health.” This act did not cover other tobacco products, such as bidi, gutka, and so on.

The “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” was passed in India in 2003. (COTPA) . The Act covers all items that include tobacco in any form, as specified in the Act’s Schedule. COTPA specifies the prohibition of direct and indirect advertisement, promotion, and sponsorship of cigarettes and other tobacco products, the showcase of a specified warning on each pack that must appear on at least one of the largest panels of the package, and the mention of nicotine and tar content on each package.

In February of 2004, the Indian government ratified the WHO FCTC. The treaty went into effect the next year and set a framework for a multi-sectoral, integrated response to a severe public health problem.

India’s health warnings policy was created in 2006. The final set of health warnings was announced in 2008, and on May 31, 2009, they were applied on all cigarette packaging. On cigarette packets, two warnings were rotated, and a separate warning was rotated on all smokeless tobacco products.

In 2011, India’s Ministry of Health and Family Welfare suggested a rule change that includes four new pictorial warnings for tobacco and bidi products, as well as four new pictorial warnings for smokeless packages. India proposed visual warnings that would cover 40% of the front of all cigarette packaging on September 27, 2012.On October 15, 2014, the government requested that larger warnings covering 85 percent of the front and rear of the pack be used to comply with international requirements.

Global Status on Health Warning Labels

The International Status Report, 2014 ranked 198 countries depending on the magnitude of their Health Warning Labels. Thailand is first with the most warnings (85%), followed by Australia with 82.5 percent size and plain packaging. With rankings of 4, 13, and 79, Nepal (75 percent), Sri Lanka (60 percent), and Pakistan (40 percent) have overcome challenges and issued large visual warnings. In comparison to other countries, India is ranked 136th (20 percent). After 143 countries, no pictorial health warnings are presented at all.

Beginning in 2012, all tobacco products manufactured in Australia for domestic consumption had to be marketed in plain packets. Tobacco industry logos, brand imagery, colours, and promotional language other than brand and product names in a standard colour, location, font style, and size are prohibited on retail packaging, according to the law. According to the research, Ireland and New Zealand have begun the legislative process to implement plain/standardized packaging, while the United Kingdom is considering doing so.

Impact of Pictorial Health Warning 

To date, research has highlighted the importance of packaging as a means of communicating with smokers, and it has backed up two main precedents established in the last decade: the inclusion of graphics and the escalating size of warnings on the pack. Fifth-generation graphic warning labels began to take hold as a result of the FCTC’s implementation, mostly replacing second- and fourth-generation Health Warning Labels.

According to a meta-analysis of experimental studies, graphical health warnings drew and held people’s attention better; they evoked strong cognitive, emotional, and fear-related responses; they evoked unfavorable attitudes toward packs and smoking; and they evoked quit intentions. Pictorial health warnings outperform verbal health warnings in terms of perceived effectiveness in terms of avoiding, reducing, and quitting smoking. Evasiveness was increased by using visual warnings. According to a study, cigarette pack warnings that are bold, massive, and use graphic images may be useful in promoting smoking cessation.

While some studies have found that pictorial health warning labels have a greater impact than text-only ones, others have found contradictory results. It has been shown that strong pictorial warnings have poorer recall than less graphic or non-graphic warnings; they do not improve teenage expectations to be non-smokers a year later; and they have no effect on non-smoking teen views about cancer or addiction.

Because the tobacco industry bears the entire cost of producing and printing health warning labels, they have been designed as a cost-effective method for preventing the marketing of tobacco products. Because packaging is not disposed soon after it has been opened, it has a higher effectiveness than other consumer items. If health warning labels are not revised on a regular basis, their impact wears off over time as the novelty wears off. To reduce the wear and tear of health warning labels, it is recommended that they be rotated on a regular basis.

Upshot

Tobacco usage is the world’s leading preventable cause of death and disease. Tobacco product packaging can be used to inform consumers about the health consequences. There has been a movement in the past few years from text warnings on the side of packs to pictorial warnings on the front of packs in a variety of sizes, colors, and images. Pictorial health warning labels are an evidence-based policy that has been shown successful by countries that have adopted them. Pictorial warnings on cigarette packs have become a global tobacco control approach due to their great exposure, practically global reach, and inexpensive cost. As a result, more effective Health Warning Labels are urgently needed to tackle the expanding tobacco catastrophe. In the coming future, more international research and coordination from member countries is required.

References

• WHO  Report  on  the  Global  Tobacco Epidemic,  2013.  Available: www.who.int/tobacco/mpower/en/ 
• WHO Framework Convention on Tobacco Control. World Health Organization 2003,  updated reprint 2004, 2005. Available: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf
• Tobacco-Composition, effects, nicotine, chemical,  health.  Available  at tobacco.yaia.com/composition.html
• Hiilamo H,  Crosbie E, Glantz  SA. The evolution  of  health  warning  labels  on cigarette packs:  the role  of precedents, and tobacco industry strategies to block diffusion.
• Health Warning Labels on Tobacco Products International Journal of Health Sciences & Research (www.ijhsr.org)   270 Vol.7; Issue: 1. 
• World health organization. WHO report on  the global  tobacco epidemic,  2014. Available:  www.who.int/tobacco/global_report/2014/en
• Reddy  KS,  Gupta  PC.  Report  on tobacco  control  in  India.  New  Delhi: Ministry of Health and Family Welfare, 2004. 
• National  Tobacco  Control  Cell. Operational  guidelines.  The  National Tobacco  Control  programme.  New Delhi,  India  –  Ministry  of  Health  and Family  Welfare.  Available:  www.mohfw.nic.in/WriteReadData/l892s/About%20NTCC.pdf
• Cigarettes  (Regulation  of  Production, Supply  and  Distribution)  Act,  1975. Available: www.lawzonline.com/bareacts/cigarettes…/cigarettes-regulation-of-production-supply 
• The  Cigarettes  and  Other  Tobacco Products (Prohibition of Advertisement and  Regulation  of  Trade  and Commerce,  Production,  Supply  and Distribution) Act, 2003. 
• Health Warnings; Tobacco Labelling Regulations. Available: www.tobaccolabels.ca/healthwarningimages/
• Canadian Cancer Society Cigarette Package Health Warnings: International Status  Report Available: https://www.tobaccofreekids.org/assets/content/press_office 2014/2014_10_14_health_labels.pdf
• Global Adult Tobacco Survey (GATS) – Ministry of Health & Family. Available:  mohfw.nic.in/

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