Pictorial Health Warning Labels in Smoking Cessation - A Systematic Review

Background: The World Health Organization's Framework Convention on Tobacco Control (FCTC) directs countries around the world to adopt pictorial health warning labels (HWLs) on cigarette packages to warn consumers about smoking-related risks. India has also implemented HWLs, and a third revision has been done with 85% coverage of cigarette packets. However, the effectiveness of HWLs in the control and prevention of smoking habits is still unclear. Objective of this systematic review: to collect evidence and evaluate role of pictorial HWLs on cigarette packs in changing smoking behaviour. Methods: A systematic and comprehensive literature survey was carried out in electronic data bases like Pubmed, Google scholar, IndMed, and Index Copernicus with MeSH terms "tobacco products" and "health" and keywords like "cigarette", "warning", "labels", and "plain packaging" for articles published until April 2017. Data collection and analysis: 850 articles were extracted, among which 113 relevant articles were shortlisted after going through titles based on the inclusion-exclusion criteria. After screening their abstracts, 31 articles were selected for this review. Results: We identified 31 studies conducted in 13 different countries, with a maximum of 7 studies from Australia. In 4 studies, international comparisons were made on the effectiveness of implemented HWLs. The outcome variables reported in this review are cognitive changes in intention to quit or avoiding, forgoing cigarettes and cessation of habit. An interaction between participants' age, educational level, and socioeconomic status with quitting rates is investigated in few studies. 22 studies identified that pictorial HWLs increase the likelihood of quitting smoking, while 2 studies did not show any significant association. Studies on plain packaging reveal its high impact in smoking cessation. Conclusion: There is fair evidence from heterogeneous studies that pictorial health warning labels are effective in changing smoking behaviour. Plain packages may be even more effective, and efforts are necessary for universal implementation. Keywords: cigarette, warning, labels plain packaging