Packing a heavier warning

Author: Ranit Mishori

Coming soon to the lives of American smokers: cigarette labels that go far beyond a simple warning.

Imagine gruesome color photographs showing a mouth riddled with cancer, lungs blackened, a foot rotten with gangrene. If the images sound sickening, well, that’s the point.

Under a law signed by President Obama on June 22 — the Family Smoking Prevention and Tobacco Control Act — tobacco companies will be required to cover 50 percent of the front and rear panels of cigarette packages with color graphics showing what happens when you smoke and bold, specific labels saying such things as:

“WARNING: Cigarettes cause fatal lung disease.”

“WARNING: Tobacco smoke can harm your children.”

“WARNING: Smoking can kill you.”

The first U.S.-mandated label in 1965 tentatively suggested “Cigarette Smoking May Be Hazardous to Your Health.” Although the language changed over time, critics have long dismissed U.S. labeling as anemic and ineffective.

Indeed, the inspiration for the new labeling standards comes from abroad. Canada started the trend in 2000 with a label that showed a picture of mouth cancer. “It’s the one that smokers remember more than anything else. Even after nine years,” says David Hammond, a researcher from the Department of Health Studies at the University of Waterloo in Ontario. Since then, he says, more than two dozen countries have picked up on the idea.

A sampling of how explicit the labels can be: Malaysia’s cigarette packs bear a photo of a diseased lung; some in Brazil show a dead fetus lying near cigarette butts; Thailand’s show a person with a hole in his throat, to warn about throat cancer; in New Zealand, it’s a gangrenous foot.

Compare these with the American warning label, which has not changed since 1985: no images, and only a small-type surgeon general’s warning that states: “smoking by pregnant women may result in fetal injury, premature birth and low birth weight.”

“Every piece of research that I’ve seen with smokers tells us that smokers think that [pictorial warnings] are more effective,” Hammond says. “U.S. smokers and consumers are getting worse health information than almost any other smoker in the world.”

While it is true that smoking rates in the United States are lower than in other countries — about 20 to 22 percent of the adult American population smokes — experts have long argued that a more powerful message would have a far greater impact on smoking habits.

One out of five American adults is still too many smokers, says Mitch Zeller, a former director of the Food and Drug Administration’s Office of Tobacco Programs. “That’s an unacceptable figure. Just because our smoking rate may be lower than other countries around the world is not an argument against graphic warnings when we still have so many people smoking in this country.”

According to the Centers for Disease Control and Prevention, more than 440,000 U.S. deaths are attributed to cigarette smoking every year. That includes deaths from heart disease, lung cancer, obstructive lung disease, other cancers, stroke and other conditions. An estimated 49,000 of these deaths are the result of secondhand-smoke exposure.

“The health effects of smoking are inherently hard and frightening,” Hammond says. “Lung cancer is not a pretty disease. Mouth cancer is not pretty. And any warning that falls short of communicating that probably isn’t doing its job.”

The bigger the warnings are and the more vivid they are, he says, the more they will make people pay attention, “particularly warnings that elicit negative emotions, like fear or disgust.”

The World Health Organization agrees. In May, the organization called for all countries to adopt picture-based warnings on all tobacco packages, calling them “among the strongest defences against the global epidemic of tobacco.” But not everybody agrees that fear and disgust are appropriate buttons to be pushing.

“We are not enthusiastic about any type of graphic image openly displayed in our stores,” says Lyle Beckwith of the Association of Convenience and Petroleum Retailing, a trade group that represents more than 2,000 retailers and their suppliers.

Philip Morris, the country’s largest manufacturer of tobacco products, supported the legislation, which, in addition to requiring stronger warnings, allows regulators to control the amount of addictive nicotine in a cigarette and bans most cigarette flavorings. The rest of the industry opposed the legislation.

Hammond does not think cigarette makers will mount legal battles, because lawsuits in other countries have failed. He said there were such challenges with the earliest graphic labels in Canada, “but the industry lost. . . . They challenged the E.U., they lost. They lost everywhere, and I would doubt that they would challenge it” in American courts.

Longtime smoker Karyn Kimberling, president of the smokers’ rights group Virginia Smokers Alliance, sees the coming labels as an attempt to “de-normalize and demonize” smokers and doubts habits would change. “Grotesque labels have not changed people’s habits in other countries,” she says, “so I don’t know why it would here.”

There is, however, research to support claims that graphic warnings educate smokers on the dangers of their habit, and even motivate some to quit. American smokers shown a set of graphic Canadian warning labels, for example, rated them “substantially more of a deterrent than text-only labels” in a CDC-sponsored study published in the American Journal of Preventive Medicine.

Similarly, an international telephone poll tested several thousand people on their awareness that smoking is linked to heart disease, stroke and lung cancer, among other illnesses. The calls were made in four countries: the United States, Canada, Australia and the United Kingdom. Researchers found higher level of awareness in Canada and Australia, and credit that to the more explicit labels in those countries. Impotence, for example, is specifically mentioned on Canadians labels, and Canadians polled were twice as likely to agree that smoking can cause impotence as were people from the other three countries.

Hammond keeps pressing the argument that “pictures are more likely to catch people’s attention and to hold people’s attention over time,” especially if the message reaches kids.

“Even the most hardened, recalcitrant smoker will often tell us, ‘Well, they don’t have an effect on me, but my 6-year-old keeps coming up to me and saying, “Daddy, this is going to happen to you?” ‘ ” Hammond says. “That does not happen with the text warning.”

Additionally, says Hammond, text warnings don’t work well with those who can’t read — mostly minority populations who don’t have a high level of literacy in English. “For those millions of people, you might as well be writing a health warning in Mandarin if it only has text,” he says. “You put a picture on it and it broadens the scope of those things to millions more people who cannot read English, many of whom are from a lower socioeconomic status and are more likely to smoke anyway.”

The legislation says that the Department of Health and Human Services “shall issue” regulations governing the upgraded labels within two years.

1. Ranit Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.

August, 2009|Oral Cancer News|

Study: Do more to help patients quit smoking

Author: Mary Wade Burnside

A survey of cancer patients being treated at the Mary Babb Randolph Cancer Center indicates that many of the smokers did not quit the habit in light of their diagnosis and some of them were not even advised to do so by their doctors.

“It absolutely benefits patients to quit,” said Dr. Jame Abraham, chief of oncology at WVU Hospitals and the medical director of the Mary Babb Randolph Cancer Center in Morgantown. “No. 1, we know that smoking can potentially alter the effectiveness of chemotherapy.

“No. 2, smoking can cause many other conditions, including lung cancer and COPD (chronic obstructive pulmonary disease), and smoking can increase the chance of getting pneumonia and lung disease, which can complicate the ability to take the treatment.”

The study was the idea of Lola Burke, now a second-year medical student who performed much of the survey work, Abraham said.

Burke sent surveys to 1,000 cancer patients, and 200 of them responded. Of the 200 who responded, 52 percent had a history of smoking, but only 20 percent had been actively smoking at the time of the diagnosis, Abraham said.

Of the active smokers, 44 percent quit while 56 percent did not, Abraham said.

“Another thing we found was that 40 percent were not told by the doctors to quit,” he added. “They didn’t even hear this from their doctors or their health-care provider.”

Bruce Adkins, director of the Division of Tobacco Prevention for the West Virginia Bureau for Public Health, has teamed up with Marshall University’s Joan C. Edwards School of Medicine in an effort to offer training to physicians who would teach them how to counsel patients to quit smoking.

“We started doing some provider training about two and a half year ago,” he said. “It’s a tough addiction to break. You have to keep reinforcing it. People don’t usually quit smoking the first time they attempt to quit. The average number of times it takes someone to quit using tobacco is eight to 10 times.”

Staff members from Marshall’s School of Medicine travel throughout the state offering a three-hour course to physicians, covering topics such as cessation counseling, spit tobacco, smoking and pregnancy, and the pharmacotherapy of tobacco cessation, Adkins said.

In 2007, the Centers for Disease Control and Prevention (CDC) reported that West Virginia had the second-highest rate of adult smokers in the United States at 25.7 percent, second to Kentucky at a rate of 28.6 percent.

The findings of the study at the Mary Babb Randolph Cancer Center, which have been released in this month’s edition of Journal of Oncology, published by the American Society of Clinic Oncology, illustrate that more must be done in order to help cancer patients quit, Abraham said.

“Many times, that person has been smoking for a long time,” he said. “That addictiveness is so high, so you can’t just walk away from this in one day.”

The news came during the same week that the CDC released a report in its Morbidity and Mortality Weekly Report stating that Kentucky and West Virginia have the highest death rates from smoking.

It also comes during the same month that actor Patrick Swayze, undergoing treatment for pancreatic cancer, admitted that he still smokes.

“We do see similar behavior all the time,” Abraham said of Swayze’s admission. “But I’m not going to blame the patient. Last week, I was talking to a patient who, because of her cancer treatment has lost her hair, and she said, ‘I know it looks ridiculous to smoke.’ She knows that, but she’s still smoking. It’s more complicated than that.”

The study was filled out by people being treated for a variety of different cancers, not just those that generally have been associated with cigarette smoking, which include cancer of the lungs, head and neck, bladder, stomach and pancreas.

“Many times, some early-stage cancer patients get cured from the primary cancer and then come back with a second cancer,” Abraham said. “We had a stage-one breast cancer patient. I gave her the treatment and I told her, ‘You’re going to be fine. There is a 90 percent chance that it’s not going to come back.’

“But she was an active smoker and two years later, she had a large mass in her lung and died of lung cancer.”

The situation frustrates anti-smoking activist Adkins, who smoked in college and was treated for cancer of the tongue three years ago, about 30 years after he quit his smoking habit.

When he had cancer, Adkins said, radiation treatments were very uncomfortable, and he could not imagine smoking during that time period.

“I could barely swallow. I could barely eat. Nothing tasted good. Everything was yucky,” he said. “Smoking could not have made that better. It could only have made things worse if I was a smoker.”

January, 2009|Oral Cancer News|