A recently completed sample-based study done in Bangladesh claims that the health warning labels describing the harmful effects of tobacco products using text and/or pictures are found to be effective.
Health warnings on cigarette packages are among the most prominent sources of information about the harms of smoking and tobacco use. Indeed, even in high-income countries where millions of dollars are spent on anti-tobacco mass media campaigns, smokers still report getting information about the risks of smoking from cigarette packages almost as much as from television, and much more than from other sources such as print media.
Therefore, in a country such as Bangladesh, where very little information about the harms of tobacco use appears on television and other broadcast media, warning labels on tobacco packages represent an even more important opportunity for informing the public about the harms of tobacco. Given their tremendous reach and frequency of exposure, health warnings are an extremely cost-effective public health intervention compared to other tobacco prevention efforts such as paid mass media advertising – these came out of a sample-based survey.
Pictures can convey a message with far more impact than can a text- only message. A picture really does say a thousand words. Pictures are particularly significant for individuals who are illiterate or who have low literacy, an aspect especially important in many countries. To ensure better visibility and impact, pictorial warnings should be placed on both the front and back of the package and not just one of these.
Pictorial warnings may be very effective in Bangladesh because smokers already demonstrate a relatively high level of awareness of the text-only labels. However, although awareness is relatively high, the current warnings have little impact on smokers’ behavior – a minority of smokers reported that the warnings made them try to avoid the labels, think about the health risks of smoking or made them think about quitting. Therefore, stronger pictorial warnings could not only improve levels of awareness of the harms of smoking in Bangladesh but also increase behavior that might motivate quitting. In addition, pictorial warnings may be more effective among people with low literacy – an important consideration in Bangladesh where about 21% of respondents in the 2010 ITC Survey were illiterate, and another 57% had less than 9 years of education.
The specific objectives of the study was to assess whether the pictorial warning label in cigarette packs influence the smoking behaviour of the smokers (of all the tobacco packs); to know whether all the tobacco products (cigarette, biri, jorda, gul etc.) were using the pictorial health labels; and to determine the reaction of the smokers seeing the pictorial health warning on the cigarette packs. Moreover, the study also reviewed the current situation in the tobacco industry; if the tobacco industry was 100% compliant on graphical health warning; and to review the global scenario.
Data was collected from 640 smokers from 8 divisional districts of Bangladesh both in urban and rural areas using structured questionnaire. Moreover, 4 focus group discussions (FGDs) were conducted. The secondary literature review also suggested that graphics health warning (GHW) were more effective.
There is extensive evidence to show that pictorial and other health warning labels on smoked tobacco products: increase health knowledge about the harms of tobacco; prevent relapse in former smokers; deter youth and adults from initiating use and experimentation; deter smokers from having a cigarette when they are about to have one; increase smokers’ intentions and attempts to quit; reduce appeal of the cigarette packs.
The use of pictures greatly increases the effectiveness of health warnings on tobacco products, and more countries are now incorporating pictures into their warnings. Pictures are effective because they catch and hold the viewer’s attention. Use of pictures in health information is also important for reaching low-literacy individuals.
A systematic review of studies in 20 countries found that strengthening pack warnings was associated with increased knowledge about the risks of smoking, reduced smoking consumption, increased quit attempts, increased short-term smoking cessation, and reduced smoking prevalence. The study reviewed extensive information regarding the global scenario in this context.
The study revealed that Pictorial/Graphical Health warnings are more understandable to 67% of the respondents.
The study collected information from 640 people from different age groups, occupation, and economic categories. Around 15% of the respondents were female while 85% were male. Around 56% of the respondents were from the age group of 19-24 years (26.6%) and 25-35 years (28.1%). Considering the urban and rural context, the educational qualification of the respondents was similar for each category. However, it varied between the rural and urban sample. The level of education was higher among the urban Population. 20.3% of the respondents were students, 21.7% were salaried employees or service holders, 23.8% were self-employed or engaged in business, 15.6% were rickshaw/van/boat/push-cart driver and 15.3% were day laborers. Respondents belonged to different economic categories – low income (32%), middle income (39%) and high income (29%) – according to their monthly income. All the respondents were cigarettes smokers. Moreover, some of them consumed multiple tobacco products i.e. 21.9% also sometimes smoked Biri, 14.1% consumed Gul or Jarda.
Findings from the primary survey revealed that 95.6% of the respondents smoked regularly whereas 96.3% in urban areas and 95% in rural areas. Out of the total tobacco users, 20.6% respondents started smoking 10 years before. 35.6% tobacco users were using tobacco during 5 – 10 years. Around 30% of the respondents started smoking 1-5 years ago. Nearly half of the surveyed population (47.5%) smoked up to 10 cigarettes per day. 15.6% smoked 11-20 cigarettes per day, 18.1% smoked 21-30 cigarettes per day and 18.8% smoked more than 30 cigarettes per day.
After the introduction of a country law on mandatory GHW, the tobacco industry is now using mainly pictorial health warning to discourage tobacco use and almost 97% respondents have noticed warnings on the tobacco products. 94.3% respondents noticed the graphical/pictorial warnings out of 97%. Only GHW was reported by However, only text warnings were noticed by 5.6% of the respondents.
Among the 97% who noticed GHW, were asked where they had noticed the pictorial messages. 95.2% mentioned about cigarette packs, 1.3% noticed the GHW in the Biri packs, 4.8% noticed it in Jarda packs and 21% noticed it in the Gul packs. This showed that the government was successful to make the cigarette companies complying with the existing law. However, other tobacco products companies such as Biri, Jarda and Gul are not complying with the rule. During FGD, the retailers also mentioned that that most of the Jorda, Gul and Biri companies are not using GHW.
The study revealed that pictorial/graphical health warnings were more understandable to 67% of the respondents and 28.1% respondent reported that they understood both graphical and text warnings. Pictorial warnings were understandable to people from all educational background. However, pictorial warnings were more understandable by female respondents.
98.1% of the respondents opined that they supported the current practice of both-side for pictorial health warnings/GHW and 77.5% respondent informed that they thought that the current use of GHW of 50% of the cigarette pack for warnings was good enough to demotivate and reduce the use of tobacco products. Considering up to 50% of the cigarette pack, around 89% were supporting this.
The findings revealed – about 72.7% of the respondents reported that they felt very unpleasant to see the pictorial warning on the tobacco packets (74.1% in urban and 72.7% in rural areas). The survey also reported that the pictorial warning was very realistic to 65.6% of the respondents and extremely realistic to 17.0% respondent (18.8% in rural and 15.3% in urban areas).
The psychological impact of GHW on the respondents was also examined. 13.9% of the respondents were extremely worried and 61.7% were very worried to see the pictorial warning on the cigarette package.
In summary, the study found that the graphics health warnings (GHW) are realistic to provide health-related information and are very effective in creating an unpleasant feeling and sense of worriedness among the smokers to aware them regarding the harmful effects of smoking.
In order to find out the effectiveness of current GHW of 50% of the label, the average number of cigarette consumed by the smokers in Urban and Rural areas before the GHW were also asked. Findings suggest that after the introduction of GHW, Cigarette consumptions has significantly reduced among the smokers. In the sample, more than 30 cigarettes per day consumptions reduced from 29.7% to 18.8% and 20-30 cigarettes per day consumptions reduced from 27.2% to 18.1% and 11-20 cigarettes per day consumptions reduced from 22.5% to 15.6%. The reduction is higher in Rural Areas. The reduction is similar for Male and Female respondents.
From the Qualitative study, the retailers recalled that there was a drop in the sale following the introduction of the pictorial messages/GHWs. They also responded that 100% of cigarette packs are using 50% Graphic Health Warning at Front and back. Pictorial/Graphic Health Warning should also be incorporated into other tobacco products i.e. Gul, Biri, Jarda etc.
75.8% respondents tried to reduce or quit smoking after seeing the pictorial warning on the cigarette packet. The rate is 76.3% in rural and 75.3% in urban areas. 83.5% respondents reported that they tried to reduce or quit smoking habit to see the pictorial warning.
The survey examined the view of the people on size and location of pictorial warning. 72.3% opined that current pictures are good enough. The respondents also provided opinion on ‘should the picture size be increased more than 50% and should the placement be changed from bottom’. 88.9% of the respondents reported that the tobacco industry may continue using these pictorial health warning and they are in favor of the current label size of 50% and placing in the bottom.
Finally, the overall effect of using improved GHW on cigarette packs was examined. 82.8% mentioned that Non-tobacco users will think twice before starting the habit, 68.4% mentioned that Tobacco users will think of reducing the habit and 45.6% users opined that Tobacco users will think to quit their habit. The qualitative review also revealed that current pictorial message/GHW are satisfactory to Majority of the respondents. Most of the respondents (smokers) think that the current pictorial messages are effective reducing the number of smokers. They said that the current pictorial messages are scary and encourage the young smokers to quit smoking and young non-smokers to discourage smoking.
74.8% recommended to include GHW in Biri, Gul and Jorda. Moreover, 64.2% respondents recommended that government should take initiative for mass awareness and 85.5% recommended for more visual media (TV) coverage. Public Service Announcements (PSA) on television is more effective than the message on cigarettes packets.