Sambrook Research International A review of the science base to support the development of health warnings for tobacco packages This report has been prepared for European Commission, Directorate General for Health and Consumers. The views expressed in this document are the sole responsibility of its authors and do not necessarily reflect the views of the European Commission. Sambrook Research International 30 Station Road Newport Ref : R 306 Shropshire 18th May 2009 TF10 7EN Tel 01952 551188 England Fax 01952 551163 E-mail : [email protected] Contents EXECUTIVE SUMMARY............................................................................. 1 Main findings and overall conclusions 1 Recommendations 4 BACKGROUND, OBJECTIVES, METHOD AND SAMPLE .................. 5 Background, objectives and overall research requirements 5 SCIENTIFIC KNOWLEDGE ON HEALTH LABELLING ..................... 7 How consumers look at packaging / labels 7 Effectiveness of warning labels generally 8 SCIENTIFIC KNOWLEDGE ON TOBACCO WARNING LABELS..... 9 Background information on tobacco warning labelling 9 Review of scientific knowledge on general tobacco warning labelling 10 Evaluation of the effectiveness of TEXT ONLY tobacco health warnings 14 Evaluation of the effectiveness of specific pictorial tobacco health warnings 20 PRINCIPLES OF EFFECTIVE TOBACCO WARNING LABELS ...... 40 Effectiveness of graphic warnings versus text only messages 40 Analysis of warning effectiveness 42 Key design parameters to create effective warning labels 46 SCIENTIFIC EVIDENCE OF HEALTH EFFECTS OF TOBACCO ... 49 Overview of the main illnesses related to smoking and second-hand smoke 49 Review of the scientific evidence of the health effects of tobacco 51 Health and other benefits from smoking cessation 80 PROPOSALS FOR NEW TOBACCO HEALTH WARNINGS.............. 81 Proposed new warning messages 81 OVERALL CONCLUSIONS AND RECOMMENDATIONS............... 108 Main findings and overall conclusions 108 Recommendations 110 APPENDICES ............................................................................................. 111 Appendix 1 – References regarding effectiveness of health warnings 112 Appendix 2 – Evidence on effectiveness of tobacco health warning labels in general 117 Appendix 3 – Evidence of effectiveness of pictorial warnings versus text only 127 Appendix 4 - Overview of tobacco warning messages used with pictorial warnings 131 Appendix 5 -Information on health labelling in non-tobacco sectors 135 Appendix 6 – The 42 pictorials used in the EU 141 Appendix 7 – Plain packaging and its likely impact 146 Appendix 8 – References regarding the health effects of smoking 149 Appendix 9 – List of people contacted for feedback 153 EXECUTIVE SUMMARY Main findings and overall conclusions • The purpose of this report is to provide the European Commission with a review of the scientific knowledge on health and tobacco labelling, an evaluation of the impact of the existing textual and pictorial warnings and a proposal for warning messages based on a state-of-the-art knowledge on tobacco-related harm. Scientific knowledge on health labelling generally • Consumers usually examine packaging in a systematic way, looking at the elements in order of visual dominance. Warning labels are more effective if they systematically address key behaviour processes – attention, reading, comprehension, recall, judgement, behaviour compliance. Scientific knowledge on the effect / impact of tobacco warning labels on consumers • There is clear evidence that tobacco package health warnings increase consumers’ knowledge about the health consequences of tobacco use and contribute to changing consumer’s attitudes towards tobacco use as well as changing consumers’ behaviour. They are also a critical element of an effective tobacco control policy. ¾ Warnings have a high impact in educating consumers of the health risks of tobacco use ¾ Warnings have a medium impact in changing smokers attitudes (in particular thinking about quitting and smoking in the presence of non-smokers) ¾ Warnings have a medium impact in changing smokers’ behaviour (including smoking less, smoking less around others, using quit lines, attempting to quit and quitting) Principles of effective tobacco warning labels • Combined pictorial + text warnings are significantly more effective than text only warnings, especially educating the public of the health risks and changing consumer behaviour. They are also more effective than text only in minimising ‘wear out’ over time. • Fear inducing warnings (using strong ‘shocking’ images related to health risks) and strong emotion inducing warnings (especially involving children and unborn babies) are the most effective way to educate consumers on the health risks of tobacco use and to achieve changes in attitudes and behaviour. These warnings’ effectiveness is enhanced if they are used in conjunction with advice on where to obtain help, e.g. a quit line. • Many warning messages have universal appeal. However, developing messages that target specific consumer groups is also of value. Certain messages clearly have higher resonance with one target group and less resonance with others. • The report provides detailed recommendations regarding the key design parameters and their optimum specification. The key parameters of importance are as follows: ¾ Size - optimally 100% and at least 50% (excluding borders) of the total facial area. ¾ Colour pictures used in all warnings together with short easily understood text messages that are clearly linked to the graphical image. ¾ Location – pictorial + text warnings should preferably be used on both sides, and as a minimum requirement on the front of packs. ¾ The warning should be hung from the top of the pack to maximise visibility. For packs that have a front opening mechanism, front warning should be hung from the ‘cut line’ (to avoid the warning being severed when the package is opened). ¾ Toll free quit line number on every pack – ideally this should be separate from the warning to avoid reducing the size (and impact) of the pictorial within the warning. 1 ¾ Plain packaging – using an unattractive standardised colour with the removal of logos / brand images and associated colours, with brand names in a standardised colour (black) and font size. Inserts that contain information on the immediate health benefits of quitting as well as advice on how to quit and details of the quit line number could also be considered. • Warnings should be optimally split into two sets, each set rotated ideally every 12 months (maximum every 18 months) to minimise wear out effects. • The optimum renewal period for the warning messages is broadly seen as every 2-5 years. If a rotation period of 12 months is adopted, then the warnings / images should be reviewed after 4 years (allowing each message to be used at least twice). Scientific evidence of the health effects of tobacco use • The key diseases associated with smoking for which the research shows there is strong evidence of a causal link are given below. DISEASES CAUSED BY ACTIVE SMOKING Cancer diseases Lung cancer (bronchus, trachea) Head / neck cancer (mouth, larynx, pharynx, oesophagus, nasal/sinus) Kidney / ureter cancer Pancreatic cancer Stomach cancer Bladder cancer Cervical cancer Leukaemia (especially acute myeloid leukaemia) Non- cancerous respiratory diseases Chronic obstructive pulmonary disease COPD (emphysema / chronic bronchitis) Other respiratory effects (asthma, coughing, phlegm, wheezing and dyspnoea) Pneumonia Cardiovascular diseases Heart attack / coronary heart disease / aortic aneurysm Angina Stroke Atherosclerotic / peripheral vascular disease Reproductive and pregnancy related diseases Male / female fertility Reduced foetal growth / low birth weight baby Miscarriage / spontaneous abortion Perinatal death Increased risk for sudden infant death syndrome Premature birth Premature rupture of the membrane Increased risk of placenta previa Increased risk of placental abruption Impotence / erectile dysfunction Other diseases Blindness / age related macular degeneration / cataracts; Ageing of the skin; Osteoporosis / hip fracture; Gastric ulcer; Dental disease; Other diseases that are associated with smoking where evidence is suggestive but not sufficient to infer a causal relationship include; anal cancer, vagina/ vulva cancer, ovarian cancer, penis cancer, prostate cancer, colorectal (bowel) cancer, liver cancer, breast cancer, chronic rhinitis, multiple sclerosis, goitre, diabetes and crohn’s disease asthma, breast cancer, rheumatoid arthritis. 2 DISEASES CAUSED BY SECOND-HAND SMOKE Diseases caused in adults Coronary heart disease; Lung cancer; Reproductive effects in women / low birth weight; Respiratory symptoms (nasal irritation) Diseases caused in children Middle ear disease; Sudden infant death syndrome (SIDS); Respiratory diseases; Other diseases that are associated with passive smoking where evidence is suggestive but not sufficient to infer a causal relationship include: Adults - nasal sinus cancer, stroke, COPD / asthma, AMD, atherosclerosis/ peripheral vascular disease and pre-term delivery. Children - brain tumours, lymphoma, asthma, leukaemia, meningitis, cognitive development and behaviour problems. Proposed new warning messages • 24 new warning messages have been developed, based on analysis of the scientific evidence, discussions during in-depth interviews and stakeholder feedback. Some have universal appeal others have additional resonance with specific age groups / gender.