China needs more effective warning labels on cigarette packs
Bernhard Schwartländer says China can raise the low public awareness of the harmful effects of smoking by requiring large pictorial health warnings to be displayed on cigarette packs
Nowhere does the global tobacco epidemic loom more ominously than in China, where there are more than 300 million smokers. Nearly 30 per cent of Chinese adults smoke, including 53 per cent of all men. Smoking kills more than 1 million people a year in mainland China - 3,000 every day - a figure that could triple by 2050 if current smoking rates are not reduced.
Tobacco use will have a potentially catastrophic effect on China's society and economy unless swift and decisive action is taken.
Most Chinese smokers are not aware of the extent of harm caused by smoking. Data from the International Tobacco Control Policy Evaluation Project shows that a majority of Chinese smokers do not know that smoking causes strokes and heart disease - two of the leading causes of death in China - and that fewer than half know smoking can cause impotence, miscarriage and oral cancer. The study showed that smokers in other countries are significantly more aware of smoking-related risks than those in China.
The most effective antidote to this lack of awareness is to have large pictorial warning labels on cigarette packaging. These have been proven to increase smokers' awareness of health risks, and to increase the likelihood that they will reduce their tobacco consumption. Although anti-smoking adverts can be effective as well, even the best mass media campaigns can't reach all smokers all the time. By contrast, health warning labels have tremendous reach and impact.
Chinese smokers consume an average of 15 to 17 cigarettes a day. Exposing them to a health warning each time they reach for a cigarette means they will see a warning up to 6,205 times a year.
Fortunately, the WHO Framework Convention on Tobacco Control provides a road map for reducing tobacco use through clear and effective warning labels. The world's first health treaty, it covers 88 per cent of the global population, having been signed and ratified by 177 countries - including China, where it has been in effect since 2006.
But although the treaty and the guidelines for its implementation adopted by the parties clearly spell out how to make warning labels effective, various studies show that, as of the end of last year, text-only cigarette health warnings in China remain ineffective and weak.
Effective warnings include pictures of the harm caused by smoking, and specifying the diseases smoking causes (such as lung cancer, heart disease, stroke and emphysema). Effective warnings also occupy at least 50 per cent of the front and back of each cigarette package. They explicitly encourage smokers to quit, and display a "quit line" number to call for information and help. Current warning labels in China do not carry any of these features.
Studies conducted to determine the efficacy of the World Health Organisation's policy recommendations have shown that when countries implement its guidelines fully, they can really "move the needle" where smoker behaviour is concerned.
China has fallen short. It has increased the size of the text on its warning labels, but does not use photos. Its warnings cover a third of the front and back of the package, instead of half, and they are positioned on the less visible bottom of the pack rather than at the top. In addition, warnings use the same colour and design as the package, rather than being graphically distinct so as to stand out. Current warning labels do not motivate Chinese smokers to quit, nor do they materially increase behaviour associated with quitting.
By contrast, in 2009, Malaysia began using pictorial warnings that occupied 40 per cent of the front of the cigarette pack, and 60 per cent of the back - in line with treaty guidelines. As a result, a far higher percentage of Malaysian smokers noticed the warnings, thought more frequently about quitting, and gave up the occasional cigarette compared with Chinese smokers. Similar results were obtained by studies conducted in Australia, Brazil, Mauritius, Thailand and Uruguay.
China's policymakers must accelerate the implementation of pictorial health warnings as a way to meet the goals laid out in its own National Tobacco Control Plan, which aims to curb tobacco use.
China's anti-smoking efforts are complicated by the fact that the government owns the country's biggest tobacco companies and factories. But other countries and regions have faced similar issues, and mainland China can learn from their experience. Hong Kong, for example, has reduced its smoking rates to about 11 per cent of the overall population.
While tobacco is a profitable product and many Chinese farmers make their living growing it, the profits from the tobacco economy can never offset the long-term economic damage wrought by the destructive effects of smoking.
Full implementation of the WHO Framework Convention on Tobacco Control and its guidelines is one of the best investments countries can make in public health, and placing large pictorial health warnings on tobacco products is one of the "best buys" available to governments seeking to control tobacco use.
For the sake of millions of its people, China must move towards full implementation with all due speed.
Dr Bernhard Schwartländer is the WHO's representative in China