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Sambrook Research International

A review of the science base to support the development of health warnings for tobacco packages This report has been prepared for European Commission, Directorate General for Health and Consumers. The views expressed in this document are the sole responsibility of its authors and do not necessarily reflect the views of the European Commission.

Sambrook Research International
30 Station Road Newport Shropshire TF10 7EN England
E-mail : info@sambrookresearch.co.uk Ref : R 306

18th May 2009 Tel 01952 551188 Fax 01952 551163

Contents
EXECUTIVE SUMMARY............................................................................. 1 Main findings and overall conclusions Recommendations 1 4

BACKGROUND, OBJECTIVES, METHOD AND SAMPLE .................. 5 Background, objectives and overall research requirements 5

SCIENTIFIC KNOWLEDGE ON HEALTH LABELLING ..................... 7 How consumers look at packaging / labels Effectiveness of warning labels generally 7 8

SCIENTIFIC KNOWLEDGE ON TOBACCO WARNING LABELS..... 9
Background information on tobacco warning labelling Review of scientific knowledge on general tobacco warning labelling Evaluation of the effectiveness of TEXT ONLY tobacco health warnings Evaluation of the effectiveness of specific pictorial tobacco health warnings 9 10 14 20

PRINCIPLES OF EFFECTIVE TOBACCO WARNING LABELS ...... 40
Effectiveness of graphic warnings versus text only messages Analysis of warning effectiveness Key design parameters to create effective warning labels 40 42 46

SCIENTIFIC EVIDENCE OF HEALTH EFFECTS OF TOBACCO ... 49
Overview of the main illnesses related to smoking and second-hand smoke Review of the scientific evidence of the health effects of tobacco Health and other benefits from smoking cessation 49 51 80

PROPOSALS FOR NEW TOBACCO HEALTH WARNINGS.............. 81
Proposed new warning messages 81

OVERALL CONCLUSIONS AND RECOMMENDATIONS............... 108
Main findings and overall conclusions Recommendations 108 110

APPENDICES ............................................................................................. 111 Appendix 1 – References regarding effectiveness of health warnings Appendix 2 – Evidence on effectiveness of tobacco health warning labels in general Appendix 3 – Evidence of effectiveness of pictorial warnings versus text only Appendix 4 - Overview of tobacco warning messages used with pictorial warnings Appendix 5 -Information on health labelling in non-tobacco sectors Appendix 6 – The 42 pictorials used in the EU Appendix 7 – Plain packaging and its likely impact Appendix 8 – References regarding the health effects of smoking Appendix 9 – List of people contacted for feedback 112 117 127 131 135 141 146 149 153

EXECUTIVE SUMMARY
Main findings and overall conclusions • The purpose of this report is to provide the European Commission with a review of the scientific knowledge on health and tobacco labelling, an evaluation of the impact of the existing textual and pictorial warnings and a proposal for warning messages based on a state-of-the-art knowledge on tobacco-related harm. Scientific knowledge on health labelling generally • Consumers usually examine packaging in a systematic way, looking at the elements in order of visual dominance. Warning labels are more effective if they systematically address key behaviour processes – attention, reading, comprehension, recall, judgement, behaviour compliance. Scientific knowledge on the effect / impact of tobacco warning labels on consumers • There is clear evidence that tobacco package health warnings increase consumers’ knowledge about the health consequences of tobacco use and contribute to changing consumer’s attitudes towards tobacco use as well as changing consumers’ behaviour. They are also a critical element of an effective tobacco control policy. Warnings have a high impact in educating consumers of the health risks of tobacco use Warnings...
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