Abstrict

Smoking is a psychosomatic addiction that is injurious to health and cause serious addiction. According to WHO, globally one of the prominent causes of death & disability is cigarette smoking, affecting all parts of body. Five million deaths occur each year. Aim of the study is to evaluate warning labels of cigarette effectiveness in advising smokers of smoking's health risks, thus motivating them to quit smoking. An evaluative survey was conducted in the Bahawalpur community by using a self-administered questionnaire as a tool to elicit data. When percentage was compared among four groups, the highest scoring was of 16–25-year age group. Next to them was the age group 25-45 & least percentage was of 45-60 age groups. Today, the labels are trivial & simply overwhelmed by the packing schemes on cigarette boxes. Additionally, smokers turn habitual zed to the elegance of brands, to the point that labels go unnoticed. Due to the lack of effectiveness of warning labels, there is a need to adopt Framework Convention on Tobacco Control (FCTC) guidelines in Pakistan. There is a need to conduct anti-smoking efforts; otherwise, the annual death toll will double if the current consumption trend continues.

Keywords

Smoking, Addiction, Bahawalpur Community

Introduction

According to the World Health Organization, tobacco use is the leading cause of death and disability globally. Modern studies suggest that the harmful habit is worse than the previously known WHO report states: currently, each one in ten adults die due to smoking (5 million deaths occur each year) (Organization & Control, 2008). The annual death toll will double within 25 years if current consumption trends continue. In Pakistan, the prevalence of tobacco smoking is 36% among males & 9% among females. The mortality rate is 58 % (Ahmed, Rizwan-ur-Rashid, & Ahmed, 2008).

Cigarette smoke contains 4000 chemicals, 200 of which are poisonous & above 60 are known to be carcinogenic (Moir et al., 2008). Data from recent studies confirmed the quantitative relationship b/w smoking & many diseases such as COPD, CVS diseases, lung cancer, bladder cancer, cataract, pulmonary emphysema, neonatal mortality etc. (Health & Services, 2006). From the last three decades, cautionary labels become the most prevalent method by way of government efforts to advise citizens about smoking's health risks. Smokers who had a habit of smoking twenty cigarettes per day are more prone to warning at least 7300 times per year (Willems, Willemsen, Nagelhout, & de Vries, 2012). By 1991, 77 countries needs health warnings on tobacco packages, yet size, number & information containing varied from country to country (Strahan et al., 2002).

This article presents the findings of a survey that aimed to establish a clear understanding of Tobacco packaging health warning labels' effectiveness in notifying smokers and non-smokers about the dangers of smoking in the BWP community. This paper will also outline various methods which can be used to improve the effectiveness of tobacco packaging health warning labels.

In 1989 Canada had a text-only label covering 20% of the pack (McQueen, 2007). Canada introduced large pictorials warnings covering 50% of the pack size in 2001 when 91% of the smokers said that they viewed the labels (Willems et al., 2012). Beginning with Canada In 2001, Canada has introduced pictorial warnings and after that 28 countries have announced pictorial warnings labels & many countries are in process. In 2007, Nicotine & Tobacco Research concluded that most of the smokers in the U.S are in the favor of graphic warning labels. After introducing picture warnings in Brazil, 67% of the smokers were as in Thailand in 2006 pictorial labels were introduced & 44% of smokers quit smoking (Wachnik, 2010).

According to FCTC 11 guidelines (Framework Convention on Tobacco Control), the cigarette package labels should have the following characteristics:

1) Appear on both front & backside.

2) It should be at the top of packages.

3) Cover 50% of the pack size.

4) Include full dark color pictures.

5) Include multiple messages about the harms of smoking

6) Provide advice about cessation (Organization, 2013; Willems et al., 2012).

After applying FCTC guidelines in many countries, which in 2008 also encouraged Pakistan's government to adopt these guidelines, the 1st pictorial warning label was introduced in Pakistan in 2010 on Gold Leaf by Pakistan Tobacco Company. The pictures can be replaced from time to time (Zaheer & Irfan, 2011).

From these studies it is concluded that one of the operative ways to deliver health possibilities to smokers is extensive, comprehensive, graphic, fear arousing labels, thus motivating them to quit smoking. Today, the labels are trivial & simply overwhelmed by the packing schemes on cigarette boxes. Additionally, smokers turn habitual zed to the elegance of brands, to the point that labels go unnoticed. Although impossible to achieve the difficulties for tobacco packaging health warning labels to devise destructive health impacts, efforts should still be made; otherwise, health risks of smoking are feared to penetrate Pakistan's general masses. 

Material and Methodology

Our team conducted the evaluative survey among three different age groups in the Bahawalpur community. The aim was to assess tobacco packaging health warning labels effectiveness in informing smokers and non-smokers about the negative impact of smoking as health warnings on tobacco packaging are the best data feed. The main objective is to evaluate how many extents warning labels are influential & what are the future requirements regarding labeling on cigarette packs.

Consequently, a survey was piloted using a self-administered questionnaire as a tool to elicit the data. It is an exclusive method & we chose it because it is the most comfortable way to read people's minds. It is simple to compile data from standardized answers. The questionnaire designed was eligible and the contents were suitable for the target population.

It addresses the relevant issues like smoking habits, awareness about health risks of smoking, prevention and methods to quit smoking. Additionally, the material also explores how much extent the tobacco packaging health warning labels are useful & whether there is a need for modifying warning labels. Smokers should quit smoking after reading the label & non-smoker should be prevented from starting smoking.

The target audience included three age groups  

• 16-25

• 25-45

• 45-60

The size of the population was 100 from each group (randomly male & female). They were asked to fill the Performa within 30 minutes. Then the percentage was calculated for each group of questions & compared among the four groups. Finally, the evaluation was done; results were tabulated & represented graphically.

? The questionnaire is divided into different categories. Group of the question evaluates how many percentages are addicted to smoking, chain smokers, smoke as a fashion, are aware of smoking risks, think that labels are influential, or need modification.

Results

• It has been concluded that the highest percentage of smoking is among adults whereas there is significantly less population who do not smoke now a day's & also lesser percentage is seen in the age group of 45-60 years.

• One of the common forms of addiction is chain-smoking. A repetition of smoking by an individual instantaneously after one is finished. The highest percentage is seen in the middle age group.

• Adults agree that they smoke as a fashion. The problem is celebrities and movies do make smoking look appealing as shown in figure 1.



• Nicotine the main constituent of Cigarettes is highly addictive. So, it’s become very difficult to quit smoking. The highest percentage is seen in the age group 16-25 years.

• Most people agree that smoking is not beneficial, so the proportion is less in all age groups. The highest ratio is among the age group 16-25 years.

• This analysis illustrates an extensive correlation among poor knowledge of tobacco use risks that can cause CVS problems and high smoking prevalence levels. Therefore, to halt this connection and decrease the lethal toll of tobacco, some precautions must be adopted to increase the specific health harms' alertness.

• Although the highest percentage is seen in young people who smoke, maximum number of smokers starts this habit as teenagers and after that try to quit. Nevertheless, they agree that smoking should be banned in Pakistan or by decreasing the nicotine concentration in cigarette at a certain level which does not cause addiction might meet this objection as shown in figure 2



• Cigarette smoking is harmful due to the chemicals present in its smoke. Although there is not an exhaustive list for the chemicals in cigarettes, however there are number of cases explain that passive smoking is more harmful than active smoking.

• The concept present in middle age group people is high that sometimes it is as simple as avoiding dust, tobacco smoke and air pollution from automobiles, industrial plants and power plants is a major cause of asthma.

• Middle-aged people are more aware about the injurious effects of tobacco that can cause peripheral vascular disease CVS, stroke. Besides, secondhand smoke leads to heart attack.

• The concept and knowledge that Tobacco use in any form greatly enhances the risk of oral cancer and smoking damages gum tissue and leads to receding gums, which exposes the teeth roots. Which in turn, this can cause tooth decay, as well as sensitivity to hot/cold foods, which is more significant in youngster's as shown in figure 3, A and B



• The cigarette warning label is a legal formality fulfilled by cigarette manufacturers. The fact is that cigarette warning labels do not affect smokers as shown in figure 4. 



• Strongly worded, specific, extensive label information on tobacco product packages provides necessary public health messages, targeting smokers. The warning/information label should ideally cover 50% of the pack's front and back areas as shown in figure 5.



• However, pictorials are much like the long-awaited metric system and soon, the metric system would take the place of the imperial system. When or if pictorials take the place of text is still of debate. However, age group (16-25 years) is more in favor of pictorial labels as shown in figure 6.



• Warning labels on cigarettes, threatening words combined with scary pictures, are popular. It is more effective to accompany the warning texts with graphic illustrations of the dangers of smoking as shown in figure 7a and 7b.

 

Figure 7a: Fear arousing labels are more effective in discouraging smokers?



• It strongly suggests that brief counseling by a doctor; dentist, pharmacist, or nurse is helpful and should be part of the curriculum. The additional facilities they deal and the more intensive the service, the more likely they are to help callers as shown in figure 8.



Figure 9

• A high proportion exists among young groups that there are several unique groups of patients for whom smoking cessation advice needs to be tailored. So a more significant proportion of people think that labels should advise cessation of smoking as shown in figure 9.



• The concept that tobacco packaging health warning labels are known to be an effective method for educating the public on the health harms of tobacco products is more in young adults above 60%

• Some countries have introduced warnings about the increased risk of heart disease or heart attack, but no country has yet implemented a label to warn people that secondhand smoke causes heart disease as shown in figure 10.

• The young age group is more aware of many methods to quit smoking. Some people like to quit immediately, while others like to reduce their smoking gradually. Either method can work, or you should select the method you are most comfortable with as shown in figure 11.



• The young age group is more aware of many methods to quit smoking. Some people like to quit immediately, while others like to reduce their smoking gradually. Either method can work, or you should select the method you are most comfortable with as shown in figure 11.



Discussion

Cigarette smoking is the most preventable cause of death in the United States, according to Health.com. The Centers for Disease Control and Prevention (CDC) indicates that cigarette smoking causes 443,000 deaths per year by causing severe and life-threatening illnesses.

Health warnings on cigarette packs are the best sources of information about smoking harms than any other source except TV. By 1991, 77 countries required health warnings on tobacco packages, yet size, num & information containing varied from country to country.Owing to the different variations among countries for warning labels packages, an opening exists to explore the impact of different warning policies on consumer knowledge.

This paper describes the outcomes of a survey that aimed to establish a clear understanding of cigarette warning labels' effectiveness in informing smokers and non-smokers about the risks of smoking in the BWP community. This paper will also outline methods that could be employed to enhance the effectiveness of tobacco packaging health warning labels & other anti-smoking efforts that can be made. 

For this purpose, a survey was conducted using a self-administered questionnaire as a tool to gain data. The target audience included three age groups 16-25, 25-45, 45-60. The size of the population was 100 from each group (randomly male & female). Then the percentage was calculated for each group of questions & compared among the four groups. Finally, an evaluation was done; results were tabulated & represented graphically.

• 85% of the age group (16-25) smokes, while 74% of (25-45) and 60% of (45-60) age group have smoked.

• As far as chain-smoking is concerned, the percentage range was less about 22-44%, with the highest 25-45 ages group & lowest of 45-60.

• 39-68% of the individuals think that cigarette is addictive. In contrast, 44% of the subjects say that adults are more likely to become addicted to smoking.

• About 35% of the youngsters of age 16-25 smoke as a fashion while of higher age group 45-60 only 23% do so.

• Among all, only 16-35% thinks that there are some benefits of smoking too.

• 40-50% thinks that they know the risks of smoking.

• 60-70% thinks that lung diseases are due to cigarette smoke.

• 40% think that smoking can lead to mouth cancer, throat cancer (60%), bladder cancer (18%), kidney cancer (14%), pancreas cancer (25%), and cervical cancer (18%).

• 35-85% thinks that smoking can stain teeth.

• The 16-25 age groups have the highest-scoring of range (average of 43%). Smoking increases the risk of impotence, affects skin, blood pressure, eyesight & fetus during pregnancy, and passive smoking is dangerous.

• An impressive result was gathered when it was asked that cigarettes should be banned in Pakistan. The highest percentage was of young ones of age 16-25, about (31%). However, only 20% of them were ready to quit smoking after knowing the risks.

• 20-40% knew the adaptive methods to quit smoking.

• As far as the modification in labels is concerned, 50 -80% think it should cover 50% of the pack, fear arousing, colored and pictorial, and cessation advice.

• Training and counseling regarding smoking cessation should be part of the curriculum; 78% agree with it.

• Finally, when the data was compiled, it indicates that among 16-25 and 25-45 age groups warning labels in Pakistan are 50-65% effective. At the same time, 45-60 age group members think that they are 42% effective. 

When viewing the results, it is clear that there is a lack of knowledge about smoking risks and how to quit smoking. Health warning labels are not effective in discouraging smokers, so there is a need to modify labeling standards. This can be achieved by following the Framework Convention on Tobacco Control (FCTC) guidelines in Pakistan.

In addition to it, other anti-smoking efforts should be made. People should be informed about the methods to quit smoking. There is a need to conduct training programs. Health care providers should counsel the patients. Training and counseling should also be part of the curriculum. Conveying information adequately and responsibly is also essential.

The knowledge about the health risks of smoking is grossly adequate. Labels are only 50-60% effective in informing smokers. 

Conclusion

Thus, the most effective way to convey health risks to smokers is with extensive, comprehensive, graphic, fear arousing labels, thus motivating them to quit smoking.

References

• Ahmed, R., Rizwan-ur-Rashid, M. P., & Ahmed, S. W. (2008). Prevalence of cigarette smoking among young adults in Pakistan. J Pak Med Assoc, 58(11), 597-601.
• Health, U. D. o., & Services, H. (2006). The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General: Atlanta, GA: US Department of Health and Human Services, Centers for Disease ....
• McQueen, D. V. (2007). Continuing efforts in global chronic disease prevention. Preventing Chronic Disease, 4(2).
• Moir, D., Rickert, W. S., Levasseur, G., Larose, Y., Maertens, R., White, P., & Desjardins, S. (2008). A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chemical research in toxicology, 21(2), 494-502.
• Organization, W. H. (2013). WHO Framework Convention on Tobacco Control: Guidelines for Implementation of Article 5. 3, Articles 8 To 14: World Health Organization.
• Organization, W. H., & Control, R. f. I. T. (2008). WHO report on the global tobacco epidemic, 2008: the MPOWER package: World Health Organization.
• Strahan, E. J., White, K., Fong, G. T., Fabrigar, L. R., Zanna, M. P., & Cameron, R. (2002). Enhancing the effectiveness of tobacco package warning labels: a social psychological perspective. Tobacco control, 11(3), 183-190.
• Wachnik, E. (2010). Anti-Smoking Legislation: Why Strong Local Legislation & Action Better Protect the Consumer than Federal Legislation & Action. Loy. Consumer L. Rev., 23, 459.
• Willems, R. A., Willemsen, M. C., Nagelhout, G. E., & de Vries, H. (2012). Understanding smokers' motivations to use evidence-based smoking cessation aids. Nicotine & Tobacco Research, 15(1), 167-176.
• Zaheer, Z., & Irfan, M. (2011). PICTORIAL WARNINGSON CIGGARETTE PACKS AND THE CONSEQUENCES ON BRAND LOYALTY AND MARKET MONOPOLY. International Journal of Academic Research, 3(5).