Update graphic images on cigarette packages to remind of health risks, experts say

Graphic warnings on cigarette packages should be updated after new research showed half of smokers did not know about all the health problems caused by smoking, Cancer Council Victoria has said.  
 
Published in the Medical Journal of Australia, the Cancer Council Victoria research – Population awareness of tobacco-related harms: implications for refreshing graphic health warnings in Australia – found that awareness of the link between smoking and a range of harms varies widely, and is as low as 27.1%, despite Australia introducing plain packaging with graphic images in 2012.
 
Cancer Council Victoria’s Acting Director Dr Michelle Scollo said it is time for stronger warnings combined with a mass media campaign.
 
‘What we need is the warnings to make sure smokers are aware of the magnitude and the number of risks they face,’ Dr Scollo told newsGP.
 
‘We need the warnings to cover more of the health issues, and they need to be updated more often ... so that people will keep looking at them and taking notice of them.’
 
There are currently 14 health warnings on cigarette packages, including blindness, gangrene and heart disease.
 
However, Dr Scollo said, in the past six years international medical authorities have issued definitive statements about other conditions are caused by that smoking, including liver, pancreatic and stomach cancers, all of which are not included on the packaging.
 
‘Why do we need the same image for lung cancer for six years [when] we could have several different images that focus on an aspect of lung cancer the warnings will then have a much longer life?’ she said.
 
‘The purpose is to ensure people understand the risks, and understanding involves emotions as well as thinking. So there needs to be an element of fear or concern for people to really understand the risk as well as the information.’

Cancer Council Victoria’s Dr Michelle Scollo says it is time for stronger health warnings on cigarette packaging.
 
The Australian Institute of Health and Welfare’s (AIHW) 2016 National Drug Strategy Household Survey shows that 12% of Australians aged 18 and over smoke at least weekly.
 
In September 2017, Cancer Council Victoria interviewed 1800 people aged 18–69, asking, “If you smoke, how likely is it that you will increase your risk of … ?”, with one of 23 health conditions caused by smoking inserted into the question. Responses of ‘very likely’ and ‘likely’ were combined and compared with the combined responses of ‘neither likely nor unlikely’, ‘unlikely’, ‘very unlikely’, ‘not sure’, and ‘prefer not to say’.
 
Dr Scollo said eight in 10 smokers knew about health problems that feature on Australian tobacco health warnings and television campaigns. However, half of the smokers surveyed did not know about 13 of the 23 listed health problems.
 
‘Lung cancer, throat cancer, emphysema, stroke and heart disease were the ones that had a very high level of awareness,’ Dr Scollo said.
 
‘But I think it is very interesting that former smokers were much more aware than the current smokers of most of the health problems.’
 
Awareness was generally highest among ‘never’ smokers, but the relative ordering of the 23 conditions from highest to lowest awareness was similar for all groups – never, former and current smokers.
 
Nine of the 23 conditions were endorsed by more than two-thirds of the sample; six cancers were endorsed by fewer than two-thirds. Only 27% of those surveyed were aware their smoking can cause ectopic pregnancy, 25% linked cigarettes to acute leukaemia, only 24% were aware smoking can cause rheumatoid arthritis.
 
Professor Mark Harris, lead author on the RACGP’s Smoking, Nutrition, Alcohol, Physical Activity (SNAP ) guide, said the research highlights the fact people still do not understand the breadth of the health problems associated with smoking.
 
‘It is a reminder we have still got a way to go in terms of the community’s awareness of the risks of smoking apart from cancer,’ Professor Harris told newsGP.
 
‘There is a high level of awareness, particularly of throat and lung cancer, but there is a lower awareness of the risks of other cancers like pancreatic, stomach and bladder cancers.’
 
Professor Harris said GPs often see patients whose smoking can exacerbate or increase risk of certain diseases.
 
‘Smoking puts you at risk of getting diabetes, but when you have got diabetes it then puts you at greater risk of developing heart disease or stroke,’ he said.
 
‘We have got very uneven levels of awareness in the community. Whereas the GP would know about the risks, their patients won’t. They may have diabetes or rheumatoid arthritis in the family, but they may not realise by stopping smoking they could reduce their risk of those conditions.’
 
According to Professor Harris, the fact research shows smokers tend to have lower levels of understanding of the risks than people who have never smoked is evidence of more than patient denial.
 
‘It is also a reminder that smokers are more likely to be from lower socio-economic backgrounds, to have lower education, and lower health literacy,’ he said.
 
Professor Harris believes more needs to be done to educate people about the risks.
 
‘Despite the fact that blindness [health warning] is on the package – it’s quite grisly and certainly eye-catching – only 44% of smokers are aware of [the risk]. They must have seen the photographs,’ he said.
 
‘That suggests to me that while it is very important to have these graphics on cigarettes, they are not sufficient. We need other ways of communicating with smokers about the risk.’
 
Professor Harris said GPs have a role to play in educating the population about the health impact of smoking.
 
‘As doctors, we need to be really pointing out what the risks are,’ he said. ‘And there needs to be signs in the practice. We do see a lot of people … for precursor conditions like bronchitis, which may be a precursor to emphysema.
 
‘So we may see people early in the course and it’s an opportunity to tell people that cancer is important, but there is a lot of other conditions as well they might get and [we need to educate them about] the importance of cigarette cessation.’

AIHW Cancer Council Victoria Medical Journal of Australia Tobacco plain packaging