A12.1.5 What has been the impact of pictorial health warnings in Australia?

Several studies have examined the impact of the 2006 warnings in Australia.1–8 These include: studies of tobacco industry behaviour and media coverage concerning the new health warnings;1–3 a study of the impact of the warnings on adolescent smoking-related beliefs and behaviours, a study of changes in awareness of warning-related health effects and motivation to quit among Victorian5,6 and South Australian smokers;7 impact of the effects of the new warnings (which include the quit line number) on use of the Quitline;9 assessment of the impact of warnings on smokers in the Australian arm of the International Tobacco Control Policy Evaluation study;10 and a comprehensive set of focus group studies and interviews commissioned by the Australian Government. Findings from each of these studies as well as data on motivators to change smoking behaviour from the National Drug Strategy Household Survey11,12 are summarised below.

A12.1.5.1 Miller et al and other implementation studies

Shortly before the implementation date for new graphic health warnings in 2006, one tobacco manufacturer sold products in 'retro'-tins from which the label could easily be removed.1 It is unknown how many smokers kept these tins for future use (allowing cigarettes to be stored in cases without the new health warnings).

 

Figure 12.1.5.1

Figure 12.1.5.1
Retro tin cigarette case marketed shortly before the introduction of the new warnings

Source: M Swanson, National Heart Foundation Australia 1

Miller et al2 monitored the roll-out of the health policy initiative using multiple methodologies. They observed that plans by government to introduce graphic warnings were delayed up to two years, apparently by heavy industry lobbying. Print media coverage of new pack warnings was observed over three years. Story content was coded as positive (supportive of pack warnings), neutral or negative. Of the 67 media stories, 85% were positive or neutral about the new warnings and 15% were negative.2 Supportive content presented health benefits. Unsupportive content presented industry arguments. While media coverage of the new warnings reported the industry arguments against them, the balance of coverage was overwhelmingly positive. An observational study of a small random sample of metropolitan stores (n = 16) over seven months measured the pace of the roll-out in shops. After the legislative change, it took two months before any new packs appeared in stores. After six months, the majority carried them.2 A similar study conducted in 40 shops in Sydney3 found that in July 2007 (16 months after the introduction date) 70% of shops were still selling tobacco products with the old health warnings. Once new packs were readily available in stores, smokers (n =152) were intercepted in city streets in Adelaide and asked about their reactions. Newest images had highest recall among smokers. Smokers' initial reactions were in line with tobacco control objectives. About 60% said new warnings detracted from the look of their brand. About 51% felt the increased risk of dying from smoking-related illness. About 38% felt motivated to quit. 2

A12.1.5.2 White, Webster and Wakefield study of Victorian adolescents

To assess the impact of the introduction of graphic health warnings among adolescents at various stages of smoking uptake, White, Webster and Wakefield conducted surveys of students at year levels 8 to 12 in greater metropolitan Melbourne in 2005 (n = 2432) and approximately six months after the introduction of the graphic health warnings in 2006 (n = 2050).4 At baseline, 72% of students had seen cigarette packs in the previous six months, while at follow-up 77% had seen packs and 88% of these had seen the new warning labels. They found that awareness of smoking as a cause of gangrene and mouth cancer (both not covered before in previous health warnings) increased substantially among students at all stages of smoking uptake. Cognitive processing of warning labels increased, with students more frequently reading, attending to, thinking and talking about warning labels at follow-up. Experimental and established smokers thought about quitting and forgoing cigarettes more at follow-up. At follow-up intention to smoke was lower among those students who had talked about the warning labels and had forgone cigarettes compared with those who had not.

A12.1.5.3 Brennan et al Victorian and Miller et al South Australian household survey studies

As described in Section A12.1.2, graphic health warnings for tobacco products sold in Australia were introduced in 2006, covering cigarette packs and their cartons, and packaging for roll-your-own and pipe tobacco. The warnings for cigarette packs were introduced in two stages, with Set A warnings covering gangrene, emphysema, mouth and throat cancer, clogged arteries, illness in children, improvement of health with quitting and scale of deaths (smoking... a leading cause of death) appearing for sale from mid-2006 13 and Set B warnings appearing for sale from early 200714 and covering lung cancer, heart disease, blindness, stroke, effects on unborn child, addictiveness of smoking and toxicity of tobacco smoke.

Researchers from the Centre for Behavioural Research in Cancer in Victoria undertook series of studies using data collected from the annual surveys of Victorian households to assess the impact of the new health warnings on adult cigarette smokers. In the first pair of studies, researchers compared awareness of those health effects covered in the Set A warnings between 2005 and 2006 among smokers and among smokers who had seen complementary TV advertisements and either had and had prior exposure with the new health warnings concerning gangrene and mouth cancer. 5 The second study compared awareness of Set A13 with Set B13 warnings between 2006 and 2007 in Victoria.6

In the first study,5 telephone surveys of two cross-sections of adult smokers measuring changes in top-of-mind awareness of smoking-related health effects from before (2005; n=587) to after (2006; n=583) the pack warnings were introduced, showed that the proportion of smokers aware that gangrene is caused by smoking increased by 11.2 percentage points (OR=23.47, p=0.000), and awareness of the link between smoking and mouth cancer increased by 6.6 percentage points (OR=2.00, p=0.006). In contrast, awareness of throat cancer decreased by 4.3 percentage points, an illness mentioned in the pack warnings but not the advertisements. People who were identified as smokers in the garget market for the Government's advertising campaign (low-SES smokers 18 to 44 years) were interviewed about their cognitive and emotional responses and intentions to quit after they had watched one of the campaign advertisements, comparing outcomes of those with and without prior exposure to the pack warnings. In multivariate analyses, smokers who had prior exposure to the warnings were significantly more likely to report positive responses to the advertisements and stronger post-exposure quitting intentions. Study authors concluded that television advertisements and pictorial health warnings on cigarette packets may operate in a complementary manner to positively influence awareness of the health consequences of smoking and motivation to quit.

The second study6 showed a significant increase among smokers in the salience of smoking-related illnesses primarily in the Set B warnings between 2006 and 2007.

Lung cancer was the most frequently spontaneously identified smoking related illness (50%), and spontaneous recall of this illness increased from 2006 (42%). Thirty-four per cent of Victorian smokers spontaneously identified heart disease/heart attack as smoking caused illness, which was a trend towards an increase from 2003 (25%). Stroke/vascular disease (Set B) was spontaneously identified as a smoking-related illness by 14% of smokers in 2007 and this was a significant increase from 2006 (8%). Top of mind awareness of eye problems increased significantly among smokers to 8% (from 3% in 2006). Spontaneous recall of pregnancy complications as smoking-related illness showed a trend towards an increase from 0.3% in 2006 to 2% in 2007. By contrast, smokers showed very low levels of top-of-mind awareness for mouth cancer (12%), throat cancer (11%), and gangrene (6%) which were the subject of the Set A graphic health warnings.13 The lower levels of awareness of the Set A health warnings following a period of non-exposure suggests that the impact of these warnings on top-of-mind awareness appears to stabilise or dissipate after a period of non-exposure. The one exception was the high proportion of Victorians who accepted the link between passive smoking and a range of illnesses, including asthma (Set A), SIDS (Set A), and pneumonia in children (Set A), which increased significantly between 2006 and 2007. This may in part have been due to the introduction of the smoking bans in hospitality venues and other media or public health activity surrounding this policy initiative.

Miller et al also made use of annual household surveys to evaluate the effects of health warnings in South Australia.7 Representative samples of South Australian smokers were interviewed in four independent cross-sectional omnibus surveys; in 2005 (n=504), 2006 (n=525), 2007 (n=414) and 2008 (n=464). Unprompted recall of new graphic cigarette warnings was high in the months following their introduction, demonstrating that smokers had been exposed to them. Smokers also demonstrated an increase in awareness about smoking-related diseases specific to the warning messages. Warnings that conveyed new information and had emotive images demonstrated greater impact on recall and smokers' beliefs than more familiar information and less emotive images.

A12.1.5.4 Miller et al study of impact on Quitline

Miller et al9 monitored calls to the Australian Quitline over four years, two years before and after the new packets were introduced. They recorded twice as many calls to the Quitline in 2006 (the year of introduction), as there were in each of the preceding two years. The observed increase in calls exceeds that which is explained by the accompanying television advertising alone. While call volume tapered back in 2007, it remained higher than before the introduction of new packets. No change was observed in the proportion of first-time callers.

A12.1.5.5 International Tobacco Control Policy Evaluation study

The impact of the graphic health warnings in Australia was assessed by comparing several indicators of impact among smokers in Australia with those of (i) UK smokers exposed to the larger-than previous text-based warnings introduced in 2003; (ii) and Canadian smokers exposed to graphic warnings introduced in 2000.10 Indicators measured over the five waves of the surveys (2002 to 2006) were: pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings. All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, Australian graphic warnings stimulated more cognitive responses than the UK (text-only) changes, and were avoided more. A further study prospectively examined the impact of health warnings on quitting activity.15 – See Section A12.1.3 for further details.

A12.1.5.6 Shanahan and Elliot review for the Australian Government

In 2009, a report by Patrick Shanahan and David Elliott prepared on behalf of the Australian Government Department of Health and Ageing was released ('the Elliott and Shanahan Research report').8 The intention of the report was to evaluate the effectiveness of health warnings (both graphic and accompanying explanatory messages) in increasing knowledge of the health effects of smoking, encouraging cessation of smoking and discouraging smoking uptake or relapse. The report also included comparisons with the impact of previous text-only warnings using data collected after the introduction of these warnings in 2006 and documented in Elliot and Shanahan's report in 2000.16

A12.1.5.6.1 Methodology

The research conducted in preparing the Elliott and Shanahan Research report included:

  • a literature review of graphic health warnings in Australia and overseas
  • qualitative and quantitative research of the effectiveness of graphic health warnings and explanatory messages on tobacco product packaging including:
    • group discussions (with 24 qualitative target audience groups divided into eight groups of committed smokers, six groups of recent quitters,i five groups of contemplatorsii and five groups of non-smokers)
    • a national telephone survey (of 1304 individuals)
    • stakeholder interviews (28 key informants from organisations involved in tobacco control).

For further information on the methodology used, see Section 3: Methodology p33–7.

A12.1.5.6.2 Report findings

Awareness of health warnings

Two out of three people involved in the telephone survey were aware of changes to tobacco and cigarette packaging made in the preceeding two years. More than one third of adult non-smokers could recall at least one specific warning. Awareness was particularly high among smokers (86%) and recent quitters (80%).

There was a decrease in the number of smokers who were aware of health messages and information on the front (from 98% in 2000 to 91% in 2008) and side (from 67% in 2000 to 46% in 2008) of the cigarette pack. However, there was an increase in the awareness of warnings and information on the back of the pack (from 62% in 2000 to 73% in 2008). A similar pattern was observed with non-smoker groups.

Readership

Readership of health information (text) among smokers and recent quitters is shown in Table A12.1.5.1.

Table A12.1.5.1
Change in readership of front, back and side of Australian cigarette packets, 2008 compared to 2000

Year

Front

Back

Side

 

Smokers

Recent quitters

Smokers

Recent quitters

Smokers

Recent quitters

2000

93%

92%

57%

45%

58%

47%

2008

80%

82%

66%

62%

41%

33%

Change in readership

-13%

-10%

+9%

+17%

-17%

-14%

Source: Elliott and Shanahan Research, 20098

The above table shows that, while readership of the front of the pack was greatest, there was a decrease in readership of the front and side of cigarette packs but an increase in readership of the back. The report notes that this appears to have been influenced by the inclusion of graphic warnings that are more prominent on the back of packs.

For further information on awareness of health warnings, see Section 5.2: Noticeability of Graphic Health Warnings, p60–76.

Importance, believability and effectiveness of health warnings

The Elliott and Shanahan Research report demonstrates that there is strong public support for the inclusion of health warnings on packs of tobacco and cigarettes. Seventy-one per cent of individuals who participated in the telephone survey indicated that it was 'very important' that health warnings be contained on tobacco and cigarettes with a further 14% stating that it was 'quite important'.

A significant majority of smokers (92%) and recent quitters (97%) found the health warnings to be believable, particularly those that referred to well-known smoking-related health issues and those that had appeared in anti-smoking television campaigns.

The report concludes that the use of graphic images has effectively increased the impact of public health messages about the health consequences associated with smoking. Those who participated in the telephone interview claimed that the use of graphic images, as opposed to text-only warnings:

  • had resulted in improved knowledge of consequencesiii
  • would help to prevent people from taking up smokingiv
  • was more effective in helping ex-smokers to stay quitv
  • helped to deglamourise smoking.

Awareness of the Quitline had improved since 2000, with 63% stating that they were aware that the Quitline telephone number was included on tobacco packs. Five per cent of interviewees said they had called the Quitline.

The report concludes that there have been significant positive movements in attitudes relating to smoking since the introduction of graphic health warnings, including an increase in:

  • knowledge of health risks associated with smoking
  • concern about the risks of smoking
  • the intention to quit.

For further information on importance, believability and effectiveness of health warnings, see Sections 5.3 to 5.8.

Wear out

The Elliott and Shanahan Research report acknowledges that there is some evidence that health warnings can lose their effectiveness once they become familiar.

Plain packaging

A majority of people (57%) agreed with a statement that cigarettes should be sold in plain packs to assist smokers to quit. Smokers acknowledged that the design and colour of cigarette packaging is an attraction to purchase or try a brand. It was also mentioned that pack design negatively impacts on recall of health warnings.

Stakeholder response to graphic health warnings

Stakeholders provided a positive response to the use of graphic health warnings on tobacco packs. Overall, stakeholders perceived that the existing range of graphic health warnings was well balanced and effective but that there were further improvements that could be made including:

  • refreshing pack design elements of graphic warnings to improve impact
  • developing and maintaining an integrated strategy in relation to graphic health warnings
  • implementing plain packaging.

For further information on stakeholders' responses, see Section 6: Stakeholder Reactions to Graphic Health Warnings, p165.

A12.1.5.7 Recommendations

The Elliott and Shanahan Research report suggests a number of improvements that were raised by consumers and stakeholders and in other research studies covered in the report's literature review. These include:

  • use clear, well-defined images to reduce confusion in identifying and understanding graphic images
  • increase the size of graphic warnings on the front of the pack to improve readership (which had declined since 2000)
  • improve readership of the side of pack by simplifying the text and including content such as tips to quit, larger Quitline number and/or simplified ingredients information
  • refresh the existing health warnings, introduce new warnings and add new images to existing text warnings to reduce overexposure and ensure the impact of the message is sustained
  • ensure that text messages are simple and clear by using non-technical language and choosing appropriate font style and size
  • further use of statistics in text warnings to increase the sense of urgency, use pronouns to personalise the messages and introduce messages that relate to social consequences
  • align graphic images used on cigarette packs with other media forms such as television campaigns
  • use graphic health warnings on other tobacco products such as cigars sold individually and on water pipes
  • introduce plain packaging to remove conflict and competition between the pack design and health warnings.

For further information on the suggestions raised in the Elliott and Shanahan Research report, see Section 7.5:Areas for Improvement and Future Consideration, p186.

A12.1.5.8 National Drug Strategy Household Survey 2007 and 2010

Among the 23% of smokers and recent ex-smokers who reported in the 2010 National Drug Strategy Household Survey12 having attempted to quit or cut down smoking in the previous year, 15.2% mentioned health warnings as being a factor motivating their behaviour. This was down from 19.4% in 2007 (shortly after introduction of the new health warnings) which in turn was higher than the 16.4% naming health warnings as a motivator in 200417 which was shortly before the introduction of the new warnings.

 

i 'Recent quitters' stopped smoking in the past 12 months.

ii 'Contemplators' refers to smokers who are considering quitting in the next six months and one month. See footnote j of the Executive Summary of the report.

iii Thirty-eight per cent of smokers and 59% of recent quitters in 2008 compared with 32% of smokers and 28% of recent quitters in 2000.

iv Sixty-three per cent of non-smokers and 54% of long-term ex-smokers in 2008 with 22% of non-smokers stating that graphic warnings have helped them from taking up smoking.

v Thirty-five per cent of long-term ex-smokers and 55% of recent quitters.

References

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2. Miller C, Hill D, Quester P and Hiller J. 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):644-9. Available from: http://eurpub.oxfordjournals.org/cgi/content/abstract/ckp089v1

3. Sanders S. Australia: WARNING: outdated pack health warnings are addictive to tobacco companies. Tobacco Control 2007;16(5):296. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/16/5/296

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5. Brennan E, Durkin SJ, Cotter T, Harper T and Wakefield MA. Mass media campaigns designed to support new pictorial health warnings on cigarette packets: evidence of a complementary relationship. Tobacco Control 2011;20(6):412-18. Available from: http://tobaccocontrol.bmj.com/content/early/2011/04/07/tc.2010.039321.abstract

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7. Miller C, Quester P, Hill D and Hiller J. Smokers' recall of Australian graphic cigarette packet warnings and awareness of associated health effects, 2005-2008. BMC Public Health 2011;11(1):238. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-11-238.pdf

8. Shanahan P and Elliott D. Evaluation of the Effectiveness of the Graphic Health Warnings on Tobacco Product Packaging 2008. Canberra: Department of Health and Ageing, 2009. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/F22B9115FD392DA5CA257588007DA955/$File/hw-eval-full-report.pdf

9. Miller C, Hill D, Quester P and Hiller J. Impact on the Australian Quitline of new graphic cigarette pack warnings including the Quitline number. Tobacco Control 2009;18(3):235-7. Available from: http://tobaccocontrol.bmj.com/content/18/3/235.full

10. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong HH, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tobacco Control 2009;18(5):358-64. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/5/358

11. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: detailed findings. Drug statistics series no. 22, AIHW cat. no. PHE 107. Canberra: AIHW, 2008. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10674

12. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: survey report. Drug statistics series no. 25, AIHW cat. no. PHE 145. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712&libID=32212254712&tab=2

13. Australian Government Department of Health and Ageing. Tobacco warnings cigarette packs set A. Canberra: AGDHA, 2006 Last modified 3 December, 2007 viewed 3 June, 2008. Available from: http://www.quitnow.info.au/internet/quitnow/publishing.nsf/Content/fact-sheet-health-warnings

14. Australian Government Department of Health and Ageing. Tobacco warnings cigarette packs set B. Canberra: AGDHA, 2006 Last modified 14 December, 2007 viewed 3 June, 2008. Available from: http://www.quitnow.info.au/internet/quitnow/publishing.nsf/Content/fact-sheet-health-warnings

15. Borland R, Yong H, Wilson N, Fong G, Hammond D, Cummings K, et al. How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction 2009;104(4):669-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19215595

16. Elliott and Shanahan Research. Evaluation of the health warnings and explanatory health messages on tobacco products. Canberra: Tobacco and Alcohol Strategies Section, Department of Health and Aged Care, 2000. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/4FA9E17EB0A1FB6ECA25776900054914/$File/warneval.pdf

17. Australian Institute of Health and Welfare. 2004 National Drug Strategy Household Survey: detailed findings. Drug strategy series no.16, AIHW cat. no. PHE 66. Canberra: AIHW, 2005. Available from: http://www.aihw.gov.au/publications/phe/ndshsdf04/ndshsdf04.pdf