Pictorial warnings on cigarette boxes in the Gulf Cooperation Council (GCC) countries need to be made stronger if they are to educate and discourage smokers, a new study has found.
The purpose of the images on the pack is to motivate people to quit smoking and help prevent smoking initiation. The health warning discourages new smokers and encourages smokers to quit by showing the direct health impact of smoking.
For the study, adults in Saudi Arabia and the United States were surveyed and asked to rate nine pictorial warnings from GCC, Australia and UK. The country of origin of each warning was masked. Tobacco control experts from different countries also rated the pictorial warnings on how effective they were.
The results of both studies showed that the warnings implemented in the GCC countries were significantly less effective at evoking emotional feelings, emotions and worry about smoking, than the warnings from Australia and the UK. The unrealistic images, inadequate expression of smoking’s impact on the human body, and lack of a strong connection to the text warning, were some of the factors weakening these warnings.
‘Slow and painful death’
Graphic warnings used in Australia depict a lung bleeding and an infant on life support, with captions indicating how smoking increases risk of stroke and harms unborn babies. In United Kingdom, a warning shows the insides of a throat suffering from cancer with a caption that reads “Smoking can cause a slow and painful death.”
In GCC, the warnings have cigarettes on them and show a burning hand holding a cigarette or a cigarette with skull on its stub.
Dr Fatimah El-Awa, regional advisor for Tobacco Free Initiative at World Health Organization Eastern Mediterranean Region, said she hopes to see changes in the graphic health warning being implemented in the GCC.
“The first thing is changing the pictorial health warning because the purpose of the pictorial health warning is to shock the user and to put the fear in the heart of the non-user so that they don’t start using it. This warning gets diluted over time if the messages are not changed. These graphic health warnings have been used in the GCC since 2011. Until today the same messages are being used. The messages have to be rotational, at least every one year.”
Since the pictorial warnings haven’t been changed, people have got desensitized. Some countries like Egypt or Djibouti change graphic warnings every six months to one year.
The health warning also needs to be very impactful. Use direct strong images and local languages, added the expert. The warning should be put on all packs. For now it is only placed on packs of 20 cigarettes but it should also be displayed on the cartons, she added.
“The GCC are moving in a steady way towards tobacco control. These are some of the first countries in the world to apply graphic health warnings,” said Dr El-Awa.
Dr Nasser F BinDhim, director, SFDA Research Center & Consulting Studies at Saudi Food and drug Authority explained that pictorial warnings in Gulf countries have not been evaluated in the past. Dr BinDhim worked on the study. This research was funded by the Deanship of Scientific Research at Saudi Electronic University.
Authors from Saudi Electronic University, Saudi Food and Drug Authority, University of Sydney, King Saud University, The Smart Health Project and King Khalid University Hospital in Riyadh worked on the study.
“The stronger the image, the more long lasting the effect. The images in the GCC are not real, they are artificially designed. They are abstract images not showing the real impact on the human body. Also, the text message under the picture is not related to the picture.”
One of the important recommendations is to not show the cigarette image in the warning. All the three images from GCC had images of cigarettes on the package, said Dr BinDhim.
“This will act as a reverse process so it will trigger cravings for trigger to smoke. The experts all agreed on the context that these images are not engaging enough. We found that one of the images was actually more appealing to people than discouraging,” said Dr BinDhim.
Use prominent images with text linked to it, he advised. Dr. Trilok Chand, specialist respiratory medicine at Burjeel Hospital said: “In the early stage when people start smoking, these warnings are very important as they notice these warnings. Once they’re heavy smokers it’s very tough.”
“Showing dreadful and scary pictures is more effective. Young people and literate people are most likely to quit through this. Show someone real suffering from cancer due to smoking. Only an image of a bending cigarette is not strong enough,” added Dr Chand.
A 2009 study found that smoking prevalence is approximately 22.6 percent among adults in Saudi Arabia. Cigarette smoking prevalence ranges from 19-40 percent among adults in GCC.