Cigarette pack health warnings can help ex-smokers stave off urge to resume smoking

The evidence to date suggests that health warnings on packs can deter non-smokers from starting to smoke and stop teens who dabble with cigarettes from becoming confirmed smokers. But it has not been clear whether they can actually help ex-smokers stay quit.

The authors base their findings on responses between 2002 and 2009 from almost 2,000 recent ex-smokers to the annual International Tobacco Control 4-Country policy evaluation survey. This monitors the impact of tobacco control policies in Canada, Australia, the UK and the US.

The authors wanted to find out to what extent ex-smokers notice health warnings on cigarette packs, and whether these are linked to a lower relapse rate.

In Canada, graphic warnings have covered half the pack surface, back and front, since 2000, while in Australia these were introduced in 2006 and cover 30% of the front and 90% of the back of packs.

Text only warnings on 30% of the front and 40% of the back of packs have been in place in the UK since 2002, while small text only health warnings have been included on the side of cigarette packs since 1984 in the US.

Over half (57.5%) of the survey participants had not started smoking again, when contacted a year later.

They were asked how often they had noticed health warnings on cigarette packs in the preceding month, whether these warnings made them think about the health risks of smoking, and whether they had helped them control the urge to smoke again.

Country of residence made little difference to the likelihood of relapse, although the level of responses to the warnings did vary by country, with more prominent warnings likely to be noticed more often.

Unsurprisingly, relapse rates were higher among those who were more exposed to cigarettes and associated cues, such as having friends who smoked.

And those who merely noticed the warnings more frequently were more likely to relapse, although this was cancelled out when urges to smoke - a predictor of relapse - were taken into consideration.

But those who said that the warnings helped them stay quit "a lot" were less likely to start smoking again over the next 12 months than those who said the warnings didn't help at all.

Their relapse rate was 41% compared with 50% among those who said they didn't find the health warnings helpful. This finding held true even after taking account of exposure to tobacco related cues, urges to smoke, and previous level of addiction.

"This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit," say the authors.

"We theorise that the mechanism by which [they] help ex-smokers to stay quit involves some sort of active use of the warnings - for example, to help generate reasons for resisting temptations to relapse, and is not something that occurs automatically," they write.

And they conclude: "We recommend that health professionals encourage all quitters to consider pack warnings as a potential tool to help counter their urges to resume smoking."

More information: Cigarette packet warning labels can prevent relapse: findings from the International Tobacco Control 4-Country policy evaluation cohort study Online First, doi:10.11136/tobaccocontrol-2011-050254

Provided by British Medical Journal