New US Surgeon General’s Report – Ideas for new tobacco health warnings on packs or are different messages required?

By Public Health Expert 30/01/2014


Associate Professor Nick Wilson, Professor Janet Hoek, Professor Tony Blakely

Picture19The recently released US Surgeon General’s report gives “sufficient” evidence of causality for 13 additional health conditions (e.g., colorectal cancer, diabetes, and stroke from secondhand smoke). In this blog post we ask if such information should be added to health warning labels on tobacco packaging in NZ, or whether other messages could more effectively deter youth uptake and stimulate quitting?

Released this month is a new report by the US Surgeon General that updates syntheses of evidence about smoking’s hazards. It reports that there is now “sufficient” evidence to say that smoking is a contributing cause of the following:

  • Colorectal cancer;
  • Liver cancer;
  • Diabetes mellitus;
  • Rheumatoid arthritis;
  • “Smoking increases the risk of dying from cancer and other diseases in cancer patients and survivors”;
  • Stroke – from secondhand smoke;
  • (And seven other conditions – omitted here for the sake of brevity).

The Surgeon General’s Report now lists a total of 15 different cancer sites that can be caused by smoking, and identifies 24 other chronic conditions. For secondhand smoke exposure, it now lists a total of five health consequences for children and another five for adults (including such major ones as sudden infant death syndrome, coronary heart disease and lung cancer). All up – a total of 49 health conditions.

The tobacco industry has consistently failed to adequately inform smokers of the myriad risks caused by smoking e.g., see comments by US Judge Gladys Kessler regarding industry fraud, deception and the delaying of corrective statements (here and here). Because tobacco companies cannot be relied upon to tell the truth about the harm their products cause, there is a clear role for government to fill the information gap and require warnings on tobacco packaging (for more about such warnings in NZ see this review article).

So should new information from this latest Surgeon General’s Report be conveyed to NZ smokers via health warnings on tobacco packaging? One perspective is “definitely yes” – since smokers can’t otherwise make the “informed adult choices” tobacco companies claim they make (e.g., see here on p4). Messages could also help smokers think about reducing harm to non-smokers as well; for example: “secondhand smoke can cause stroke in non-smokers”.

But are these informational messages the only approach the Government should use? We believe they should also test warning messages that deal with broader issues. For example, the message in the “we don’t smoke the shit” picture above that has been used in a Norwegian campaign. Such anti-tobacco industry messaging has been used extensively in the US (see for example these two parodies of the industry in brief YouTube clips (here and here)), and there is good evidence this message style deters young people from smoking.

Also international studies show health warnings are more effective when they arouse emotion than when they engage reason. We have growing evidence that young people rationalise and reject information about the health risks of smoking, but are more responsive to messages outlining the social risks of smoking (the smell, and potential social rejection).

How might we select the best set of messages and warnings to put on cigarette packs? Although surveys, focus groups and laboratory testing are options to continue with, another is field testing by making TV commercials of each type of potential health warning and then running these on TV for a week each (with all commercials also showing the Quitline number). This approach allows monitoring of calls to the Quitline (within an hour of each advertisement showing) and comparison of different formats’ effects, as in this previous NZ study. The best messages could then be used on packs – as well as in potentially in larger mass media campaigns.

There are many issues to consider when optimising pictorial health warnings on tobacco packaging. New information from the Surgeon General’s Report might help – but we need to explore whether messages could be more effective in deterring new smokers and enhancing cessation in the majority of smokers who want to quit.

We believe work into smoke-free messaging is important, but note it is not an end in itself and must occur alongside other critical measures that will progress the 2025 smokefree nation goal. These measures include topics canvassed elsewhere, including continuously raising tobacco taxes, phasing out retail outlets, reducing the supply of tobacco released for sale, or even denicotinising tobacco.