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The findings may be especially timely for policymakers in the United States, since the U.S. Food and Drug Administration is poised to mandate graphic anti-smoking images on cigarette packaging in September.
One expert said he believes smokers and ex-smokers need more reminders of the ravages of smoking.
"I keep an empty package of cigarettes at hand when talking to smokers, and ask them if they look at the warnings," said Dr. Len Horovitz, pulmonary specialist at Lenox Hill Hospital in New York City. "While most say that they do, they cannot repeat more than two health risks -- usually lung cancer and emphysema are the responses."
Horovitz believes that more prominent warnings -- especially about non-lung-cancer conditions such as heart disease, bladder cancer and erectile dysfunction -- would help more ex-smokers stay that way.
The new findings, published April 25 in the journal Tobacco Control, are based on a poll involving about 2,000 former smokers in Canada, Australia, Britain and the United States.
The content and graphic nature of cigarette-package warnings varies widely between these countries, the authors noted. Regardless of nationality, however, the survey found a common trend: ex-smokers who said they found anti-smoking messaging on packaging helpful were more apt to avoid relapse.
"This study provides the first evidence that health warnings can help ex-smokers stay quit," researchers led by Dr. Ron Borland of the VicHealth Centre for Tobacco Control at the Cancer Council Victoria in Carlton, Australia, said in a journal news release.
The team believes the anti-smoking messages "help generate reasons for resisting temptations to relapse."
In the United States, public health messaging on cigarette packaging is now the subject of considerable debate and potentially dramatic change. The FDA has already approved plans to overhaul the packaging of all cigarettes sold in the United States by replacing text-only warnings (in place since 1984) with extremely graphic cautionary images, some of which depict smoking-related disease.
Although a court battle over the FDA's plan is now underway, nine such images already have been composed, illustrating things such as a smoker exhaling through a tracheotomy hole in his neck and a mother and child enveloped in a cloud of cigarette smoke. Images would cover the top section of all cigarette packs.
One expert believes these images and warnings will help cut U.S. smoking rates.
"Although U.S. citizens are not routinely exposed to warning labels on cigarette packs, many have seen graphic commercials and advertisements related to the health effects of tobacco use," said Patricia Folan, director of the Center for Tobacco Control at the North Shore-LIJ Health System in Great Neck, N.Y. "When these types of commercials are aired, calls to state smokers' quit-lines have increased dramatically. This increase in calls indicates that the ads appear to be motivating smokers to quit."
In Canada, similar graphic warnings have been in place since 2000, covering half of each pack's surface on both sides. Since 2006, graphic warnings have covered 30 percent and 90 percent of the cover and back, respectively, of all cigarette packs sold in Australia. In the United Kingdom, text-only warnings have taken up 30 percent and 40 percent of the respective fronts and backs of all packaging.
The survey was conducted between 2002 and 2009. Smokers were tracked for a year, at which point they indicated their thoughts on package messaging exposure, as well as their current smoking status.
In all, nearly 58 percent of smokers who had quit remained free of cigarettes by year's end. Those who said they viewed such messages as very helpful had a relapse rate of 41 percent, compared with a rate of 50 percent among those who said the messages were not particularly helpful.
Meanwhile, another international study also published in the same issue of Tobacco Control suggests that during the next two decades the global rate of smoking will barely drop unless governments improve their anti-smoking policies.
In the study, a team led by Dr. David Mendez, of the department of health management and policy at the University of Michigan's School of Public Health in Ann Arbor, looked at the situation in the 60 nations that account for 90 percent of all smokers (and 85 percent of the world's population). They speculate that unless these countries' governments change course and push for effective anti-smoking initiatives by 2030, the global rate of smoking will fall by only 1.7 percent.
If these nations were to adopt the World Health Organization's 2008 package of anti-smoking measures, however, global smoking prevalence would drop from roughly 24 percent today to about 13 percent by 2030.
Such measures include the implementation of tobacco monitoring, second-hand smoke exposure protection, cessation assistance, publicity about health dangers, bans on cigarette advertising, and cigarette taxation.
The study authors noted that the nations with the largest smoking populations include China (28 percent of the world's smoking population), India (11 percent), Indonesia (5 percent), the United States (5 percent) and Russia (4 percent).
-- Alan Mozes
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