With the unveiling of nine graphic images that will adorn every cigarette pack sold in the U.S. starting in fall of 2012, government officials and outside experts predict there will be an initial wave of smokers seeking help in quitting. But they caution that regulators will have to refresh — and possibly dial up — their message so that consumers don't grow complacent about the omnipresent warnings.
The graphic labels released Tuesday are "an important and powerful tool" in the fight to reduce tobacco-related disease and death, said Food and Drug Administration Commissioner Margaret Hamburg. She estimated the new campaign could induce as many as 213,000 of the nation's 46 million cigarette smokers to quit in just the first year of the campaign. The American Lung Association warned local quit lines to brace for a deluge of phone calls.
Hamburg and other officials also stressed that the FDA will continue to study the effect the images have on the public, and will likely update the images yearly in an effort to keep them and their message fresh in consumers' minds. Outside experts said the U.S. government will have to vary its messages to avoid what psychologists call "wear out."
The nine images chosen by the FDA — the first update to cigarette-package warnings in a quarter century — are stark and often disturbing, and each is accompanied by simple text informing cigarette buyers of the known consequences of their habit. One of the nine appears to depict a recently autopsied cadaver and states simply, "Smoking can kill you."
Another, set against the warning, "Cigarettes are addictive," shows a man blowing cigarette smoke out of the tracheostomy hole in his throat.
Other warnings make a clear appeal to smokers' concern for others, an approach that research has found highly effective in getting smokers to try quitting. In one, a photo of a distraught woman bears the warning, "Tobacco smoke causes fatal lung disease in nonsmokers"; in another, a toddler clutched to the chest of an adult gazes anxiously at a nearby swirl of smoke, accompanied by the message, "Tobacco smoke can harm your children."
Only one of the images conveys hope and encouragement to the dwindling number of Americans who cling to their smoking habit despite growing social isolation and, in almost four-in-five smokers, a strong desire to quit. In it, a robust, 30-something man with a sharp-looking goatee and a determined stare pulls open his shirt to reveal a T-shirt that declares, "I Quit." The text reads, "Quitting smoking now greatly reduces serious risks to your health."
The new initiative is the most dramatic of the steps taken by the FDA since the 2009 Family Smoking Prevention and Tobacco Control Act gave the agency expanded regulatory powers over tobacco. It is also the first time in 25 years that the health warnings on the packaging of tobacco products has been updated beyond the bland statement, in small type, that the Surgeon General of the United States has determined cigarette smoking to be harmful to human health.
The new warnings didn't impress everyone on Tuesday.
"They're obnoxious," said Long Beach, Calif., resident Bob Kohl, a 60-year-old smoker of 43 years who was diagnosed two years ago with emphysema and has quit three times. "They are insulting. They are very specifically condescending, which irritates me. It's nothing I haven't seen before, and it's going to be meaningless to the kids, because their attitude is worse than mine."
In requiring the graphic warnings, the United States joins some 40 other countries around the world that already require cigarette packaging to carry prominent — and often very grim — warnings on the dangers of smoking. Canada and Europe pioneered the practice, and several developing countries, including Mauritius, Uruguay, Thailand, Malaysia and India, have also preceded the United States in requiring such graphic anti-smoking messages.
Starting Sept. 22, 2012, the images and related text will cover the top half of each cigarette package sold in the United States, making them "new mini-billboards for prevention," said Dr. Howard Koh, assistant secretary for health at the Department of Health and Human Services.
The warnings, added William Corr, deputy secretary of HHS, "will forever change the look" of the 15 billion packs of cigarettes purchased by Americans annually. The mandated package coverings "tell the truth," Corr said, contrasting them with messages crafted by the tobacco industry, which spends $12.5 billion annually to advertise its wares.
The images were culled from a group of 36 candidates circulated for public comment starting last June by the FDA. In choosing the nine labels, the agency ruled out a number of far more disturbing images, including an unsparing photograph of a bald lung cancer victim hollowed out by her disease.
But as the American public grows inured to the effects of the new images, the FDA might well turn to images it may have passed over as too grisly and discouraging to American smokers, experts said. As it escalates the shock value of the images it presents to smokers, the FDA must thread a careful path between simply sticking to the facts and presenting images and warnings in ways that are attention-grabbing enough to break through smokers' resistance and discouragement, said Geoffrey Fong, lead researcher of the International Tobacco Control Policy Evaluation Project at the University of Waterloo in Canada.
"It's a really good start," Fong said. "But we also need to recognize where people in the United States are right now, which is no exposure to these kinds of images."
Fong, who has studied the effectiveness of Canada's 2001 introduction of graphic warning labels, said while those warnings had a powerful impact on smokers' intentions to quit in the first two to three years, their sway with consumers declined markedly — by 30 percent to 60 percent — between 2003 and 2009, when Canada stuck with the same warnings.
The messages "don't have to be more intense, they could just be different," Fong added. "With the harms of smoking, you have a lot to choose from; you're not going to be running out of ideas."
The views of activists and researchers influenced the FDA's deliberations in other ways as well. During the months-long comment period, a wide range of experts urged the FDA to add a toll-free number to each image that will lead callers to help with quitting. The FDA acted on the recommendation, affixing the tagline "1-800-QUIT-NOW" to each image it chose. Several researchers stressed that the inclusion of a "quitline" number on the warnings was crucial in prompting smokers moved by the warnings to act on their response.
"Everything we know about frightening and scaring and persuading people is that you want to give them a place to go, or an action to take, to avert the consequences you're warning them about," said Joseph Cappella of the Center of Excellence in Cancer Communication Research at University of Pennsylvania's Annenberg School for Communication.
State, local and non-profit smoking cessation groups should gear up for a major influx of callers as the new warnings hit the streets, urged the American Lung Association.
"No smoker should hear a busy signal or be placed into voicemail when they are finally ready to make the life-saving decision to quit smoking," the association said in a statement released Tuesday.
In an interview Tuesday, FDA Commissioner Hamburg expressed hope that the new campaign would energize anti-smoking efforts nationally. Tobacco use currently claims 443,000 American lives per year and costs the United States $200 billion in lost productivity and added health care costs.
They will have their work cut out for them. Nationally, 21 percent of American adults continue to smoke and among them are the most addicted and most discouraged. And though smoking rates have declined dramatically since their peak near 40 percent in the 1960s, they have declined little in the last decade.
Meanwhile, some 4,000 teens a day try their first cigarette, and one in four will go on to take up the habit.