By Siphesihle Gwambe & Catherine O. Egbe
Globally tobacco kills more than 8 million people a year, with an estimated 1.2 million persons dying from the consequences of being exposed to secondhand tobacco smoke.1 Tobacco use is associated with several chronic diseases such as cancer, heart disease, stroke, chronic obstructive pulmonary disease, and pneumonia.2 Most of this disease burden occurs in low-middle income countries which includes countries in Sub-Saharan Africa, where smoking prevalence is currently on the rise.3 South Africa has one of the highest tobacco use prevalence in Africa with an estimated 29% of adults aged 15+ years using at least one form of tobacco product according to data from the Global Adult Tobacco Survey-South Africa conducted in 2021.4
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The World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) was developed in response to the tobacco epidemic. To date, 182 countries have ratified the WHO FCTC,5 including 44 African countries with South Africa ratifying the WHO- FCTC in 2005. The WHO’S FCTC provides a framework on tobacco products packaging,6 with guidelines such as Article 11 providing recommendations on the implementation of labelling and packaging of tobacco products.
The guidelines for implementation of Article 11 noted that larger health warnings with pictures are “more likely to be noticed, better communicate health risks, provoke a greater emotional response and increase the motivation of tobacco users to quit and to decrease their tobacco consumption” compared with small textual health warnings.7 Health warnings are also recommended to cover 50% or more, but no less than 30%, of the principal display areas (PDA) of tobacco packages.7 The guidelines also encourage countries to ensure warnings cover more than 50% of the PDA and aim to cover as much of the PDA as possible given the fact that the larger the size of HWLs, the more effective it would be.3 In addition, health warnings are required to be in the nation’s major language(s) and should include pictures which depict the health effects of tobacco use.8
The implementation of graphic health warning labels (GHWLs) on tobacco packaging is guided by the rationale that every person has a right to be informed of the health consequences, addictive nature and threat posed by tobacco consumption and the package is one of the best ways to do that.9,10
Health warnings on tobacco packaging are among the most direct and cost-effective means of communicating the health risks of tobacco use.11 Evidence has shown that combined written and graphic health messages on the packaging of tobacco products are more effective than text-only warnings in communicating the risk of smoking to smokers and non-smokers.1 Moreover, GHWLs on tobacco packages reduce the appeal of smoking to young people and motivate them to think about refraining from initiating use. It is estimated that a person who smokes a pack of cigarettes a day is exposed to health warnings more than 7000 times in one year,12 therefore packs provide an educational intervention to encourage quitting. GHWLs are also opportunities for governments to counter tobacco industry tactics to recruit new tobacco users because warning labels serve as a powerful prevention intervention which can provide crucial health information to young people who have not yet initiated tobacco use.
As previously mentioned, the guidelines for implementing Article 11 of the WHO FCTC encourage the implementation of GHWLs showing pictures of tobacco-related diseases on tobacco packages which will increase public education of the health risks associated with tobacco use. Thus, health warnings are able to disrupt the impact of a tobacco brands imagery on package and decrease the attractiveness of the package.13 Countries such as Australia, Iceland, Canada, Thailand, and Sweden were among the first countries to regulate their tobacco packaging as a means of restricting the promotion of tobacco products.14 Furthermore, there are 13 countries in Africa which have successfully implemented GHWLs on tobacco products.11 A study evaluating the effectiveness of Kenya’s pictorial health warnings in comparison to Zambia’s single text-only warnings, found that pictorial health warnings in Kenya led to an increase in all measures of health warning effectiveness which were described as behavioral reactions, warning salience and cognitive reactions.11 In comparison to pictorial warnings in high-income countries, such warnings in low-middle income countries may be more likely to have a positive equity impact on health.15
The implementation of GHWLs is important particularly among populations with basic or low literacy. South Africa has an adult literacy rate of 87%, ranking below countries such as Mexico and Brazil.16 However, the last census figures for languages spoken in South Africa show that English is the fourth spoken language and only spoken by 9.6% of the population as their first language. Though English is one of the 11 official languages in the country, it is the only language in which current textual health warnings on tobacco packages are written in South Africa. Thus, pictures would be important especially to non-English speakers, unskilled workers, as well as individuals from minority language groups who may not yet be able to read the national language(s).10
The current South African Tobacco Products Control (TPC) Act of 1993 (as amended in 2008)17 allows for textual health warnings which must cover 15% of the front of the package, 20% of one of the long sides of the package and 25% of the back of the package.18 Thus the size of current health warnings in South Africa is well below the WHO FCTC recommendations. Furthermore, it is important to note that health warnings should not be static and, must be revised or updated to maintain their effectiveness over time.19 For example Brazil has revised its health warnings three times; in 2002, 2004 and 2008.20 However, South Africa has eight rotating text-only health warnings which have not been changed since 1995!17
On a positive note, a new bill has been going through the legislative process in South Africa since 2018 when it was first put out for public comment. The Tobacco Products and Electronic Delivery Systems Control (TPEDS) Bill of 2022 seeks to introduce plain (standardized) packaging as well as pictorial health warnings on all packages of tobacco products among other measures. This bill, when passed, will replace the attractive packages of tobacco products with GHWLs on plain packages that will make it almost impossible for smokers and non-smokers to ignore the health effects of tobacco use.
The tobacco industry has consistently opposed GHWLs, with claims that strong warning labels will either demonize smokers leading them to be outcasts, cost too much, or would violate tobacco companies’ freedom of speech and trademark rights.14,21 In opposing HWLs, the tobacco industry has previously argued that the public was already aware of the hazards of tobacco use and claimed that health warnings conflict with other national laws and international treaties. 13 Interestingly, research shows that the industry identified GHWLs as a global threat to their business as early as 1985, and attempted to slow the spread and implementation of GHWLs.13 Countries such as Uruguay have faced legal challenges brought forth by the tobacco industry,22 Philip Morris International in Uruguay responded to the implementation of GHWLs by suing the country in domestic and international courts, the country was able to successfully defend the regulations.22 British American Tobacco in Kenya took the government to court in order to seek an appeal that would delay the implementation of health warnings in the 2014 Tobacco Control Regulations. The industry claimed that the GHWLs would be expensive to implement within one financial year.23 There are numerous other examples of the tobacco industry delaying the implementation of health warnings by taking country governments to court. The South African government should therefore be prepared to defend this important public health intervention from the commercial and vested interest of the tobacco industry when the 2022 bill is passed and finally becomes law.
In conclusion, it is hoped that South Africa would soon be joining many other countries in Africa and beyond who have put in place GHWs and plain packaging of tobacco products. The passing of the TPEDS Bill of 2022 will be a good public health intervention to promote awareness of the harms of tobacco products and encourage those who currently use these products to quit while discouraging young people from initiating use.
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Siphesihle Gwambe is a Senior Research Technician while Catherine Egbe is a Specialist Scientist at the Alcohol, Tobacco and Other Drug Research Unit, in the South African Medical Research Council
1. World Health Organization. Evidence Brief: How Large pictorial health warnings on the packaging of tobacco products affect knowledge and behaviour. 2022. https://www.euro.who.int/__data/assets/pdf_file/0006/276558/How-large-pictorial-health-warnings,-Evidence-Brief-Eng.pdf
2. Centres for Disease Control and Prevention. Health Problems Caused by Secondhand Smoke. Accessed 11 January 2023. https://www.cdc.gov/tobacco/secondhand-smoke/health.html
3. Singh A, Owusu-Dabo E, Britton J, Munafò MR, Jones LL. “Pictures Don’t Lie, Seeing Is Believing”
Exploring Attitudes to the Introduction of Pictorial Warnings on Cigarette Packs in Ghana. Nicotine & Tobacco Research. 2014;16(12):1613-1619.
4. National Department of Health, South African Medical Research Council, Centres for Disease Control and Prevention, World Health Organization. Global Adult Tobacco Survey [Fact Sheet South Africa]. 2021. https://www.health.gov.za/wp-content/uploads/2022/05/Global-Adult-Tobacco-Survey-GATS-SA_FS-Populated__28-April-2022.pdf
5. World Health Organization. The WHO Framework Convention on Tobacco Control: 10 Years of Implementation in the African Region. 2015:54. Accessed 22 March 2023. https://www.afro.who.int/sites/default/files/2017-06/who-fctc-10-year_report_web.pdf
6. Balhara YPS, Gupta R. Revised Size of Pictorial Warning on Cigarette Packages—A Step in Right Direction. Nicotine & Tobacco Research. 2015;17(11):1401-1402. doi:10.1093/ntr/ntv023
7. World Health Organization. Guidelines for implementation of Article 11: WHO Framework Convention on Tobacco Control. Accessed 5 April 2022, https://fctc.who.int/publications/m/item/packaging-and-labelling-of-tobacco-products
8. Woelbert E, d’Hombres B. Pictorial health warnings and wear-out effects: evidence from a web experiment in 10 European countries. Tobacco Control. 2019;28(e1):e71. doi:10.1136/tobaccocontrol-2018-054402
9. Miller CL, Hill DJ, Quester PG, Hiller JE. Response of mass media, tobacco industry and smokers to the introduction of graphic cigarette pack warnings in Australia. European Journal of Public Health. 2009;19(6):644-649. doi:10.1093/eurpub/ckp089
10. Canadian Cancer Society. Cigarette Package Health Warnings: The International Status Report. 2021. Accessed 22 March 2023. https://www.tobaccofreekids.org/assets/global/pdfs/en/WL_status_report_en.pdf
11. Kaai SC, Sansone G, Meng G, et al. Quasi-experimental evaluation of Kenya’s pictorial health warnings versus Zambia’s single text-only warning: findings from the International Tobacco Control (ITC) Project. Tobacco Control. 2021:tobaccocontrol-2020-056396. doi:10.1136/tobaccocontrol-2020-056396
12. Green AC, Kaai SC, Fong GT, Driezen P, Quah ACK, Burhoo P. Investigating the effectiveness of pictorial health warnings in Mauritius: findings from the ITC Mauritius survey. Nicotine Tob Res. 2014;16(9):1240-1247. doi:10.1093/ntr/ntu062
13. Hiilamo H, Crosbie E, Glantz S. The evolution of health warning labels on cigarette packs: The role of precedents, and tobacco industry strategies to block diffusion Tobacco Control. 2012;doi:DOI: 10.1136/tobaccocontrol-2012-050541
14. Cunningham R. Tobacco package health warnings: a global success story. Tobacco Control. 2022;31(2):272. doi:10.1136/tobaccocontrol-2021-056560
15. Shang C, Huang J, Cheng K-W, He Y, Chaloupka FJ. The Association between Warning Label Requirements and Cigarette Smoking Prevalence by Education-Findings from the Global Adult Tobacco Survey (GATS). Int J Environ Res Public Health. 2017;14(1):98. doi:10.3390/ijerph14010098
16. Shoba S. South Africa’s literacy rates plunge deeper as learning time is lost. https://www.dailymaverick.co.za/article/2021-09-13-south-africas-literacy-rates-plunge-deeper-as-learning-time-is-lost/
17. Vellios N. South Africa- Country Profile. Accessed 11 April 2022, 2022. https://tobaccotactics.org/wiki/south-africa-country-profile/
18. Campaign for Tobacco-Free Kids. Tobacco Control laws. https://www.tobaccocontrollaws.org/legislation/country/south-africa/pl-health-warnings
19. Hammond D, Reid J. Health warnings on tobacco products: International practices. Salud pública de México. 06/01 2012;54:270-80. doi:10.1590/S0036-36342012000300009
20. Thrasher JF, Villalobos V, Szklo A, et al. Assessing the impact of cigarette package health warning labels: a cross-country comparison in Brazil, Uruguay and Mexico. Salud publica de Mexico. 2010;52 Suppl 2(0 2):S206-S215. doi:10.1590/s0036-36342010000800016
21. Crosbie E, Glantz SA. Tobacco industry argues domestic trademark laws and international treaties preclude cigarette health warning labels, despite consistent legal advice that the argument is invalid. Tob Control. May 2014;23(3):e7. doi:10.1136/tobaccocontrol-2012-050569
22. Crosbie E, Sosa P, Glantz SA. Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International. Tob Control. Mar 2018;27(2):185-194. doi:10.1136/tobaccocontrol-2017-053690
23. Australian Council on Smoking Health. BAT loses major case against printing gory images on cigarette packets (Kenya). Accessed 22 March, 2023. https://www.acosh.org/bat-loses-major-case-printing-gory-images-cigarette-packets-kenya/