From Dysfonction érectile - Tobacco Info No. 5 - April 2011
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The wins and losses in Canada’s new tobacco package warning system

By Garfield Mahood, OC

(The author played a major role in the development of Canada’s two world precedent-setting warning systems in 1994 and 2001 and wrote an expert report on the subject for the World Health Organization.  He is an Officer of the Order of Canada.)

The federal government deserves praise for producing a refreshed tobacco package warning system after a long gestation period.  Now that the dust has settled from a significant struggle to have the new system enacted, Canada may very well still have the best overall warning system in the world.  But praising the decision to finally turn development efforts into real warnings should not be interpreted as a blanket endorsement of what was announced in Part I of the Canada Gazette.   After all, the system proposed in Part I is not all that it could be or, indeed, all that Canadian experts in tobacco warnings almost certainly advised the government that it should be.  If Health Canada is responsive to the criticisms of the health community related to the Part I announcements, the proposed warnings could be improved greatly before they become law when published in Part II of the Canada Gazette.

What we won

Clearly new cigarette warnings occupying 75% of both major faces of cigarette packs is a significant step forward.  So is the valuable toll-free quit line and the referral to a cessation website incorporated in the warnings.  And the elimination of the misleading toxic constituent panel on the side of packages has to be a big step forward, even if it has been replaced by a message about constituents that is so bland that it will rapidly become invisible.

Yes, the two Barb Tarbox warnings are winners.  So is the oral cancer warning.  These represent major steps forward.  Strong, emotion-packed images on these three warnings create needed punch.  And the introduction of improved graphics to the interior package information system is another welcome improvement.

What we lost

But before we fall all over ourselves with lavish praise, let’s remind Health Canada and the minister that the government could have done better and can still do better.  The proposed new reforms have, after all, excluded key elements of Canada’s current world precedent-setting system.  But first, some background.  In English speaking Canada – and I suspect the legal obligations are similar in Quebec – manufacturers have a tort or civil law duty to warn their customers of both the nature of a risk from their products (e.g. cigarettes cause lung cancer) as well as the magnitude or severity of that risk (e.g. “if you contract lung cancer, 8 times out of 10 you die,”).  This is important.  Research shows that Canadians have a generalized awareness that cigarettes are “bad for you” but often have no real knowledge of how bad, or what happens if you contract a given disease.

Death is the most severe outcome of a disease and it is critical that a warning inform smokers in easily understandable language of their chances of experiencing that outcome.  Of the 12 new warnings, where terminal disease is a risk factor, 8 fail to warn of the most serious risk, that tobacco can kill.  The existing system warns of death from second-hand smoke, from tobacco use during pregnancy, from stroke, heart disease and emphysema.  However, the language of the new warnings has been weakened and fails to mention the most severe element of these risks.  Where is the existing warning that 85% of lung cancer victims die, 80% within 3 years?  And while we are at it, where is the warning of death in the new bladder cancer warning?

Unfortunately, there are more problems with the exterior warnings, both in content and in graphics.  Health Canada has said that low literacy is a problem with the understanding of many of the existing warnings.  Yet it has produced a “vision loss warning” that is loaded with precisely this flaw.  Ditto with important language being buried in subordinate clauses, and long sentences that any ad agency copywriter or newspaper editor would shorten for greater readability.

The government claims that it wants to improve on its graphic presentation.  Yet it has proposed red texts on black backgrounds.  Red is a colour that is extremely hard to read on black.  This becomes painfully obvious on smaller flip top boxes.  Yellow text would be more legible. 

The new addiction warning has a strong graphic but the text is less instructive and impactful than what we have in the existing exterior major face warning.  How addictive are cigarettes?  We are not told in this new warning.  It demonizes nicotine, completely unnecessarily, when many in the health community are encouraging provinces to pay for nicotine replacement therapy (NRT).  The new warning could correctly say that cigarettes are the source of the addiction as in the current major face warning.  Putting a spotlight on nicotine creates reluctance on the part of many smokers to use NRT.

The loss of the interior warning system

Another significant disappointment in the Part I announcement when compared to the world precedent-setting interior system we have now is both the reduction in the variety and impact of the package’s interior “information” messages, and the complete loss in the interior system of more detailed risk messages.  (The interior messages are printed on the back of the slide of the shell and slide package or on disposable package inserts.)  After all, one of the major values of the interior system is the element of surprise.  A smoker, for example, cannot reject a particular interior message which has a negative emotional impact because the interior messages are unknown to the purchaser (e.g.  male smokers rejecting a package at point-of-purchase because it carries an external warning of impotence).  

Unlike the existing system, all of the proposed interior messages are cessation messages.  Experts in tobacco warnings would and undoubtedly have advised Health Canada that a mix of interesting, more detailed interior warnings with cessation messages is more effective.  Inexplicably, in reducing the interior messages from 16 to 8, half of the interior system, Canadians have lost the valuable “brain injury”/stroke warning, the “If I have lung cancer, what are my chances of surviving” warning, the critical heart attack warning, a superior addiction warning, and a strong emphysema/chronic bronchitis warning.

Many of these problems can be addressed.  The most important fix is that eight detailed interior risk messages be added at Part II.   Changes can be made quickly as we learned when the current warnings were being developed in 1999.  Grammar and colour changes need not be difficult.  The sub-texts on exterior warnings, the magnitude of risk element, can also easily be improved.  All that is required is a political interest in making the refreshed warnings as good as they can be.  Such political interest was present from 1999 to 2000.  Given the government’s leadership on other aspects of the tobacco file, let’s hope that Health Minister Leona Aglukkaq wants warnings that are as effective as they can be.

This commentary is preliminary and not a comprehensive review of the Part I Canada Gazette announcement.  Individuals or health organizations interested in making submissions in response to the legal invitation to submit proposals at Part I may wish to contact the Non-Smokers’ Rights Association for an even more detailed critique of the system now planned.  Contact the NSRA at (416) 928-2900 or toronto@nsra-adnf.ca.