Hong Kong’s plan for bigger health warnings on cigarette packs is backed by solid research

In 2007, Hong Kong became one of the first jurisdictions in Asia to implement graphic warnings on tobacco packaging, occupying 50 per cent of the pack. However, these warnings have remained unchanged on the pack for a decade.

But this is about to change. This week, the Hong Kong government is tabling a law calling for an increase in size of its warnings from 50 per cent to 85 per cent of the pack, doubling the number of warnings, from six to 12, and adding the hotline number for smokers who want to quit.

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Studies from the International Tobacco Control Policy Evaluation Project provide evidence supporting these proposed changes. Beginning in 2002, the project has conducted research in 28 countries, covering over half of the world’s population, including China, South Korea, Thailand, Malaysia, India, Bangladesh, Australia and New Zealand within the Asia-Pacific region, to evaluate the impact of tobacco control policies. We have conducted over 60 studies of the impact of warning labels, and a number of these studies have measured what happens when governments revise their warnings, such as introducing graphic images, changing the positioning of the warnings on the pack, and increasing the size.

First of all, there is a clear need to revise the warnings in Hong Kong because of the “wear-out” effect – messages that are repeated over time lose their impact and need to be refreshed. The studies showed the wear-out effect of warnings across a diversity of countries, including Canada, the United States, Australia and Mauritius. Canada was the first country to introduce pictorial warnings in 2001, when it implemented 12 graphic warnings taking up 50 per cent of the pack. But from 2002 to 2011, noticing the warnings dropped by over 25 per cent, their impact on thinking about the risks of smoking dropped by 35 per cent, and the impact on thinking about quitting dropped by nearly half.

However, when Canada revised its warnings in 2012, including increasing their size from 50 per cent to 75 per cent of the pack, the number of smokers reporting that the warnings made them think about quitting doubled.

Hong Kong’s warnings have remained unchanged for nearly a decade, well beyond the two to three years that the World Health Organisation and leading authorities recommend as the interval for revising warnings. Indeed, of the 12 jurisdictions that had introduced graphic warnings by 2007, Hong Kong is the only one that has not revised them. Thailand has revised its graphic warnings three times; Panama has done so six times.

Second, there is strong research evidence corresponding with common sense that larger warnings have greater impact. Experimental studies conducted by the Canadian government demonstrated that increasing warnings from 50 per cent to 75 per cent, 90 per cent and 100 per cent enhanced their impact. Larger warnings were rated by adult smokers, youth smokers, and youth non-smokers as being more effective for communicating health risks, changing social attitudes towards smoking, reducing smoking initiation, and helping smokers to quit.

Countries that have increased the size of their warnings have been challenged by the tobacco industry. In a recent high-profile case, Philip Morris International brought a challenge against Uruguay under a bilateral investment treaty to nullify the increased warning size from 50 per cent to 80 per cent, claiming there was no evidence that increasing the size of warnings was effective. The dispute was heard by a panel of the World Bank’s International Centre for Settlement of Investment Disputes.

A study of the Uruguay warning labels, which was presented to the panel, found that the increase in warning size was associated with a significant increase in the impact of Uruguay’s warnings.

In July 2016, the dispute centre rejected the company’s claims, ruling in favour of Uruguay. It also required the company to pay all court costs as well as Uruguay’s legal defence costs.

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Hong Kong’s proposal to add the “quitline” number to the warnings is also strongly supported by the international evidence. Studies from Canada, the Netherlands, Australia, New Zealand and Brazil show that adding the number to warning labels led to significant increases in call volumes. In turn, counselling programmes that have been implemented through such numbers have been shown to increase the percentage of smokers making attempts to quit and reduce the probability of relapse.

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Warning labels are a proven effective, and cost-effective, measure for empowering smokers to quit and motivating youth not to start smoking. The long-overdue proposed enhancements to the warnings in Hong Kong are not radical – they are well-justified and have strong support from international studies. Their implementation will make Hong Kong a global leader once again in this critically important public health measure.

For those who believe that enhancing warning labels is inappropriate, this rhetorical question from a Canadian tobacco control expert is right on target: “What warning labels would be appropriate for a consumer product that kills half of its regular customers?”

Geoffrey T. Fong, PhD, is professor of psychology and public health at the University of Waterloo in Canada, and senior investigator at the Ontario Institute for Cancer Research. He is the chief principal investigator of the International Tobacco Control Policy Evaluation Project