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NAQC Newsroom: Tobacco Control

News coverage of new rule on warning labels

Wednesday, June 22, 2011  
Posted by: Natalia Gromov

PROVIDED BY THE CAMPAIGN FOR TOBACCO - FREE KIDS

Print, online and TV coverage have all been extensive and prominent. In many ways, the release of the warning labels has been a great public education campaign, especially in the promotion of 1-800-QUIT-NOW. USA TODAY's front page has the word WARNING in huge type size at the top of the front page over the new warnings.

NBC and CBS nightly news did segments last night. You can watch here:

NBC: http://www.msnbc.msn.com/id/3032619/

CBS: http://www.cbsnews.com/video/watch/?id=7370869n&tag=cbsnewsTwoColUpperPromoArea

View more examples of media coverage of FDA new rule on warning labels.

Graphic new warnings unveiled for cigarettes

Rob Stein

22 June 2011

The Washington Post

Copyright 2011, The Washington Post Co. All Rights Reserved

For decades, cigarette makers seduced consumers with images of the stoic Marlboro Man, the partying Joe Camel and the liberated Virginia Slims woman who had "come a long way, baby."

On Tuesday, the federal government unveiled a plan designed instead to shock customers with images of tobacco's impact: sick smokers exhaling through a tracheotomy hole, struggling for breath in an oxygen mask and lying dead on a table with a long chest scar.

Starting next year, cigarette cartons, packs and advertising will feature these and six other graphic warnings, replacing the discreet admonitions that cigarette manufacturers have been required to offer since 1966.

The tobacco companies, several of which are challenging the new rule in court, refused to comment on the startling images that will now have to dominate half of the front and back of each carton and pack and 20 percent of each large ad.

The requirement is the most visible exercise of new powers granted to the Food and Drug Administration by Congress in 2009 to fight the nation's leading cause of preventable death. It is also the first major overhaul of cigarette warnings in a quarter-century.

The color images include a diseased lung, a mouth with discolored teeth and a disfigured lip, a weeping woman and a cartoon of a crying baby in an incubator. The graphics will include messages such as "Warning: Cigarettes are addictive," "Warning: Cigarettes cause cancer" and "Warning: Smoking can kill you."

Each brand must rotate all the images randomly throughout the year. Every warning will also include "1-800-QUIT-NOW," a hot line smokers can call for help to kick the habit.

The FDA predicts that the images, which are designed to disgust and unnerve all ages, will reduce the number of smokers by 213,000 by 2013 and save $221 million to $630 million every year over the next 20 years.

"With these warnings, every person who picks up a pack of cigarettes will know exactly what risk they are taking," Health and Human Services Secretary Kathleen Sebelius said at a White House briefing announcing the new mandate.

The final nine images were selected after the agency reviewed scientific literature and more than 1,700 public comments, and evaluated the 36 images proposed in November in a study involving 18,000 people.

Some of the more graphic possibilities - a man who appeared to be suffering a heart attack, one depicting a corpse in a coffin and another of a corpse in a morgue with a toe tag - were rejected in favor of a wide range of images that include arresting pictures as well as less dramatic ones, such as a photo of a mother holding a child and a man wearing a T-shirt that says "I Quit."

"Sometimes with the most graphic images people sort of tune them out because they are so disturbing," said Lawrence R. Deyton of the FDA's new Center for Tobacco Products. "The images that work best are the ones that people can look at and have an emotional impact but not dismiss."

The FDA will evaluate the warnings continually and update them periodically if research indicates that people are becoming inured to their impact.

"We'll begin the studies to make sure that we are keeping people sensitized," Sebelius said. "What may seem quite shocking at the beginning, people get used to quite quickly."

Some of the images, particularly the warning depicting a diseased mouth, are specifically aimed at dispelling the notion for teens that smoking is cool.

"We want kids to understand smoking is gross, not cool, and there's really nothing pretty about having mouth cancer or, you know, making your baby sick if you smoke," said FDA Commissioner Margaret A. Hamburg. "So some of these are very driven to dispelling the notion that somehow this is cool and makes you cool."

Public health authorities and anti-smoking advocates hailed the new warnings as a milestone in the battle against tobacco in the United States that began in 1964, when the surgeon general first declared cigarettes a public health threat.

In 1966, cigarette companies began warning smokers that "Cigarette Smoking May Be Hazardous To Your Health." The warnings went through several modifications over the years but remained in small text on the sides of packages and ads.

Smoking rates fell steadily for decades but have stalled in recent years, with one in five adults and teens still smoking. Smoking kills an estimated 443,000 Americans each year, costing nearly $200 billion in medical bills and other costs. President Obama struggled for years to quit.

"These new warning labels have the potential to encourage adults to give up their deadly addiction to cigarettes and deter children from starting in the first place," said John R. Seffrin, chief executive of the American Cancer Society.

The new warnings are being challenged in court by several major tobacco companies, including R.J. Reynolds Tobacco, Lorillard Tobacco and Commonwealth Brands. The companies referred queries about the new warnings to comments they submitted to the FDA. The comments labeled the images "ideological" because they do "not simply convey information intended to enable smokers to make informed decisions about whether to smoke cigarettes" but are designed to "elicit loathing, disgust, and repulsion."

Altria, the parent company of Philip Morris, which is the only tobacco company to support the FDA's new powers, also criticized the requirement for the new warnings. The company called the mandate a "last-minute" addition that failed to enable Congress to consider "alternative, less speech-restrictive warnings." Philip Morris is the nation's largest cigarette maker, producing such popular brands as Marlboro, Virginia Slims and Parliament.

At least 30 other countries require graphic warnings, including some, such as in Brazil, that go even further than the U.S. messages.

Some studies have indicated that graphic images, paradoxically, can make smoking seem more appealing to some people. But Canada, which became the first country to require more graphic warnings, has seen a significant drop in smoking since it issued the mandate in 2000.

The warnings are part of the FDA's broad new anti-smoking strategy. The agency has restricted the use of the terms "light," "low" and "mild," banned the use of fruit, candy and spice flavorings and is considering taking action to prevent the sale of menthol cigarettes.

"The tobacco companies continue to spend billions of dollars to play down the health risks of smoking and glamorize tobacco use," said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids. "These new warnings will tell the truth about how deadly and unglamorous cigarette smoking truly is."

In a new, controversial push against smoking, the FDA will require graphic photos on cigarette packs

Gary Strauss, USA TODAY

22 June 2011

USA Today

A.1

© 2011 USA Today. Provided by ProQuest Information and Learning. All Rights Reserved.

Will graphic images of corpses, cancer-ridden lungs and a guy exhaling smoke through a tracheotomy hole in his neck stub out cigarette consumption?

The Food and Drug Administration which has chosen nine such images to be placed prominently on cigarette packs sold in the USA after September 2012 hopes they'll provide ample shock value.

In the most sweeping anti-tobacco effort since the surgeon general's warning became mandatory on cigarette packaging in 1965, the FDA said Tuesday it will begin requiring tobacco marketers to cover the top half of cigarette boxes and 20% of tobacco advertisements with nine bluntly graphic anti-smoking images.

The goal: Slash consumption among the nation's 43 million smokers and prevent millions more, especially teens, from ever starting. The FDA selected the grisly images, which include pictures of rotting teeth and gums, from 36 proposed last year. Cigarette marketers also will be required to place 1-800-QUIT-NOW numbers on new packaging.

"These labels are frank, honest and powerful depictions of the health risks of smoking," said Health and Human Services Secretary Kathleen Sebelius. "With these warnings, every person who picks up a pack of cigarettes is going to know exactly what risk they're taking."

The images are the biggest change to cigarette warning labels since 1984, when the government began requiring that cigarette packs and tobacco ads carry several health warnings.

Cigarette consumption has dropped from about 42% of the population since the mid-1960s but has remained at about 21% since 2003, or about one in five adults, despite federal and state excise tax increases that have boosted prices to more than $5 a pack.

Anti-smoking laws restrict or ban smoking in 35 states and 3,270 municipalities, according to the American Nonsmokers' Rights Foundation, an advocacy group based in Berkeley, Calif. The government hopes to cut the percentage of smokers across the USA to 12% by 2020 and reduce the number of deaths tied to tobacco use, now at about 443,000 a year.

The FDA's move which faces a challenge by tobacco marketers in federal appeals court next month after a lower court ruling upheld the government's regulatory power over new packaging, imaging and warning labels is a major advance for the anti-tobacco movement.

"With 10 million cigarettes being sold every minute and more than 2,000 children under the age of 18 starting to smoke each day, we don't have a moment to lose in protecting the American public, especially children, from the harm caused by these dangerous products," says O. Marion Burton, president of the American Academy of Pediatrics.

"This is a huge step forward in encouraging kids not to smoke and adults to quit," says Paul Billings, vice president of policy and advocacy for the American Lung Association.

Shown the image of the man with the tracheotomy, teenager Conner James says it would prevent him from lighting up.

"I'm not going to smoke. I don't want a hole in my neck," says James, 14, of Washington, D.C.

'These messages are better'

About 40 countries, including Canada and Mexico, already require similar graphic warnings, according to the Campaign for Tobacco- Free Kids.

Gregory Connolly, professor at Harvard University's School of Public Health and director of its Center for Global Tobacco Control, says the images aren't as scary and over the top as Canada's images, which he notes have not lowered that nation's smoking rates.

"These messages are better," he says. "They show respect for smokers and adverse health consequences."

A recent international study from the Centers for Disease Control and Prevention found that generally, such images are effective. About 25% to more than 50% of smokers say they make them more likely to quit.

"Research evidence shows that these images make a real difference," says Sherry Emery, a senior researcher for the Institute for Health Research and Policy at the University of Illinois at Chicago.

"No other product is as fundamentally deadly, and we've known that for over 40 years. These images may help bump that out of background noise to something people might think more actively about."

Smokers and non-smokers were split on the potential impact.

"It's discrimination," says Trahesa Mires Davis, a 46-year-old Washington, D.C., resident who says she has been smoking for 20 years.

"They already hit us with all these taxes on cigarettes," Davis says. "Now they are making us put up with this. I know the risks of smoking. Why don't they do something about alcohol addiction instead of always picking on us?"

Houstonian Kevin Spangler, whose brother-in-law lost a lung because of smoking, says young people might be most affected.

"When they see something like (these images), I think it goes a long way towards taking the 'cool' out of smoking," says Spangler, 44.

Trish Kershaw, a 26-year-old Washingtonian, seems indifferent.

"I've seen (pictures like that) before and it's not pleasant to look at," Kershaw says. "But I'm used to people telling me not to smoke."

Some health specialists say the graphic warnings may offer only temporary deterrence and that smokers who repeatedly see such graphic images may become desensitized to the message about the health risks of smoking.

"We become immune to the negative warnings over time," says Jonathan Whiteson, director of the Cardiac and Pulmonary Wellness and Rehabilitation Program at New York University's Langone Medical Center.

"The more graphic the image, the more likely the message will become marginalized."

The impact on teens

Anti-smoking efforts aimed at kids produce mixed results.

The American Legacy Foundation's 11-year "Truth Campaign," funded by the tobacco industry's 1999 settlement with state governments, is considered among the most effective.

The effort tells kids that tobacco marketers want to entice them to smoke to replace the thousands of older smokers who die each year. Teens aware of the campaign were twice as likely as others to say they had no plans to start smoking, according to a 2008 study by Health Education Research.

By contrast, teens who saw Philip Morris' "Think Don't Smoke" campaign had more positive attitudes toward tobacco companies.

"The so-called youth prevention campaigns that the tobacco industry runs are a farce," says Erika Sward of the American Lung Association.

The new labeling requirements "are a great improvement," Harvard's Connolly says.

"The diversity of these images might help strike that one person that might decide now is the time to stop."

Connolly is unsure there will be long-term decreases in consumption without backup anti-smoking efforts. The FDA should regulate not just what's outside cigarette packages, but also the product itself, he says.

A Harvard School of Public Health survey of 1,000 U.S. adults, being released today, finds that more than 70% of Americans favor reducing nicotine to non-addictive levels, but only half want an outright ban on cigarettes.

A concern for convenience stores?

Major cigarette makers have opposed labeling plans since the FDA was given the power to regulate tobacco products in 2009 under the Family Smoking Prevention and Tobacco Control Act.

Several major tobacco marketers, including Reynolds America, Lorillard and National Tobacco Company, are challenging provisions of the government's regulatory authority in U.S. 6th Circuit Court of Appeals in Cincinnati in July.

Among other things, the companies are citing their constitutional right to free speech.

Reynolds America declined to comment Tuesday, while Marlboro marketer Philip Morris, the nation's largest cigarette-maker, didn't return calls.

On Wall Street, tobacco stocks were little changed. Philip Morris parent Altria Group closed at $27.31, down 1 cent, while Reynolds lost 8 cents to $38.17. Rival Lorillard gained 79 cents to $111.89.

Brannon Cashion, president of branding consultants Addison Whitney, says tobacco marketers have done a good job dealing with growing anti-smoking efforts. What they need to do is stress innovation, such as developing low nicotine and electronic cigarettes, Cashion says.

"The cigarette companies are in an environment where their product is seen as dangerous," he says.

"In order to continue to manufacture the product, they have to continue to put innovations in place that can do everything possible to make as safe an environment as possible for those who smoke and the people most affected with their smoking."

Convenience stores, which sell about 85% of the cigarettes sold in this country, could take a hit because of the new labels.

"There are unique challenges that cigarette sellers face," says Jeff Lenard, spokesman for the National Association of Convenience Stores.

"A future beyond cigarettes could be complicated. You'll see stores selling more items like food to make sure they aren't hurt."

Contributing: Wendy Koch, Liz Szabo, Luke Kerr-Dineen, Natalie DiBlasio and Carolyn Pesce; Jim Carroll of The (Louisville) Courier- Journal

U.S. Selects Cigarette Warning Images

By DUFF WILSON

22 June 2011

The New York Times

Copyright 2011 The New York Times Company. All Rights Reserved.

Federal health officials released on Tuesday their final selection of nine graphic warning labels to cover the top half of cigarette packages beginning next year, over the opposition of tobacco manufacturers.

In the first major change to warning labels in more than a quarter-century, the graphic images will include photos of horribly damaged teeth and lungs and a man exhaling smoke through a tracheotomy opening in his neck. The Department of Health and Human Services selected nine color images among 36 proposed to accompany larger text warnings.

Health advocacy groups praised the government plan in the hope that images would shock and deter new smokers and motivate existing smokers to quit. The images are to cover the upper half of the front and back of cigarette packages produced after September 2012, as well as 20 percent of the space in cigarette advertisements.

''These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit, and prevent children from smoking,'' Kathleen Sebelius, the secretary of health and human services, said Tuesday in a statement.

The four leading tobacco companies were all threatening legal action, saying the images would unfairly hurt their property and free-speech rights by obscuring their brand names in retail displays, demonizing the companies and stigmatizing smokers.

The government won one case last year in a federal court in Kentucky on its overall ability to require larger warning labels with images; the specific images released Tuesday are likely to stir further legal action. The Kentucky case is before the United States Court of Appeals for the Sixth Circuit.

The new labels were required under landmark antismoking legislation giving the Food and Drug Administration power to regulate, but not ban, tobacco products. The Family Smoking Prevention and Tobacco Control Act required F.D.A. action on the graphic warning labels by Wednesday, two years after President Obama signed it into law.

The United States was the first nation to require a health warning on cigarette packages 45 years ago. Since then, at least 39 other nations, including Canada and many in Europe, have imposed more eye-catching warnings, including graphic photos.

''This is a critical moment for the United States to move forward in this area,'' the F.D.A. commissioner, Dr. Margaret A. Hamburg, said in an interview. ''The trends in smoking really support the need for more action now. For four decades, there was a steady decline in smoking, but five to seven years ago we leveled off at about the 20 percent level of adult and youth smoking in this country.''

Dr. Lawrence R. Deyton, director of the F.D.A.'s Center for Tobacco Products, said the government estimates, based on other countries' experience, that the new warning labels will prompt an additional 213,000 Americans to quit smoking in 2013, the first full year with the graphic labels.

''We are pleased with the images they picked,'' said Nancy Brown, chief executive of the American Heart Association. ''They strongly depict the adverse consequences of smoking. They will get people's attention. And they will certainly be much more memorable than the current warning labels.''

Gregory N. Connolly, a professor and tobacco expert at the Harvard School of Public Health, also praised the strength of the warnings, but said the F.D.A. needed to take tougher action against cigarettes. ''What's on the pack is important, but if you really want to cut smoking rates, you've got to get inside the pack and deal with ingredients like menthol and nicotine,'' he said.

The nine images chosen in the United States include some that are among the most graphic of the 36 draft images. But they also include some of the less vivid, including a cartoon depiction of a baby rather than a photo in the draft set that showed a mother blowing smoke at a baby.

The images, which are to appear on cigarette packs on a rotating basis, also include one of a man proudly wearing a T-shirt that says: ''I QUIT.''

All of the packs will also display a toll-free telephone number for smoking cessation services.

The F.D.A. has already proposed nine text warnings to be paired with the images, including: ''Warning: Cigarettes cause cancer'' and ''Warning: Quitting smoking now greatly reduces serious risks to your health.''

The government surveyed 18,000 Americans of all ages to determine which of the 36 proposed labels would be most effective to deter smoking. The F.D.A. can revise the selection of images in the future.

A few smokers surveyed on New York sidewalks were unswayed by the images. Khariton Popilevsky, 46, a pawnbroker, shrugged and said: ''Telling me things we already know. I'll still be smoking.''

Hayley Sapp, 28, a paralegal, said: ''There are lots of other high risks out there, you know. Obesity is huge.''

Saiful Islam, 34, a convenience store clerk, said higher prices would cut sales a lot more than the images on cigarette packs.

A submission to the F.D.A. by R.J. Reynolds, Lorillard and Commonwealth Brands, the second, third and fourth largest United States cigarette makers, said the ''nonfactual and controversial images'' were ''intended to elicit loathing, disgust and repulsion'' about a legal product.

Those companies and others filed suit in Kentucky in August 2009 over provisions of the law. Judge Joseph H. McKinley Jr. of Federal District Court in Bowling Green, Ky., ruled that the companies could be forced to put graphic warning labels on the packages but said they could not be forced to limit marketing materials to black text on a white background, saying that was too broad an intrusion on commercial free speech.

Gregg Perry, a spokesman for Lorillard Tobacco, said on Tuesday that the company was reviewing the graphics and would not comment at this time. A spokeswoman for R.J. Reynolds repeated its earlier opposition to the graphic labels. The Altria Group, the largest tobacco company in the United States, said it would not comment.

Altria, the parent company of Philip Morris, the only major tobacco company to support the overall F.D.A. legislation, said in a letter this year that the graphic warning provision was an unconstitutional part of the law ''added in a last-minute amendment.''

The rate of smoking in America has been cut roughly in half, to about 19 percent, from 42 percent in 1965. Smoking remains the leading cause of preventable death, killing 443,000 Americans a year, according to the Centers for Disease Control and Prevention. Each day, the government says, an estimated 4,000 youths try their first cigarette, and 1,000 a day become regular smokers.

Cigarette warnings getting graphic ; FDA reveals new labels required on packages, ads

Deborah Kotz; Neena Satija

22 June 2011

The Boston Globe

© 2011 New York Times Company. Provided by ProQuest Information and Learning. All Rights Reserved.

Cigarette packages will soon be splashed with horror-movie-style warning labels showing corpses, diseased lungs, and rotted teeth, which were among nine new images unveiled yesterday by the Food and Drug Administration. By September 2012, cigarette manufacturers will be required to place these images across the top half of every pack, with large-type warnings such as "smoking can kill you" and "cigarettes are addictive."

The new images will replace the small white warning boxes that have adorned cigarette packages unchanged for more than two decades; they are required under a federal law passed in 2009 that gave the FDA regulatory authority over cigarettes. The same new warnings will appear on print ads and must take up at least 20 percent of the ad space.

"The new graphic warnings will make a powerful difference," FDA Commissioner Dr. Margaret A. Hamburg said in an interview. "Research demonstrates that they encourage smokers to quit and nonsmokers to not start."

Packages will also contain the 1-800-QUIT-NOW toll-free telephone number, she added, to provide smokers with a resource to help them quit.

Greg Connolly, a professor at Harvard's School of Public Health and former director of Massachusetts' tobacco control program, called the new labels "a marvelous improvement over what we've had for over 25 years." But he cautioned that they won't work unless they're accompanied by a mass media campaign, similar to ads that Massachusetts and some other states have aired featuring "real people telling real stories."

While graphic warning labels appear to galvanize people to quit in the short term, there is no evidence that those smokers quit for good, he added.

Some 43 countries, including Canada, Great Britain, and Brazil, already require large graphic warnings on cigarette packages, and a European Union directive gives its 27 member countries the option of adding pictures to warnings as a way to educate smokers about risks.

A 2006 study found that two-thirds of smokers in four countries that have graphic warning labels reported that the package was an important source of health information and strongly associated with an intention to quit smoking.

David Pham, a Boston financial analyst, remembers his reaction when a friend offered him a cigarette from a Canadian box featuring the warnings. "I didn't even want to smoke anymore . . . I told him I'll pass," said the 28-year-old. But while he's been trying to quit ever since, he still smokes up to a pack a day. "When you need a fix, you're still going to buy it," he said as he puffed on a cigarette outside his office near South Station.

Matthew Myers, president of the nonprofit advocacy group Campaign for Tobacco-Free Kids, said the current warning labels have lost their effectiveness and the new, more graphic warnings "counter images that the tobacco industry is seeking to project - that smoking makes a person strong, cool, and independent."

Indeed, one can clearly see the consequences of a smoking- induced heart attack in the face of a man, lying with his tie askew, whose nose and mouth are covered with an oxygen mask. While warning labels will no longer mention lung cancer and emphysema, they will show tobacco's devastating effects through images of smoke seeping out of a tracheotomy hole in a smoker's neck.

Connolly was concerned that some of the labels could be seen as demeaning to smokers. "People just turn off," he said. And he also noted that the industry has a track record of countering federal regulations.

Last year, the FDA banned the sale of tobacco products with descriptors such as "light," "low," or "mild," saying they misled consumers to believe that such products were less damaging to their health than other cigarettes. But manufacturers replaced the words with colors that critics say convey the same message. And a recent Harvard School of Public Health survey found that an overwhelming majority of smokers of brands formerly labeled light, medium, or ultra-light said they could easily identify their usual brand of cigarettes by color, even without the descriptors. "That's not a good success story," said Connolly.

The results of the survey will be released today at a conference examining FDA regulation of tobacco.

Cigarette manufacturers are challenging the legality of the new labels in a federal lawsuit and say the size of the warnings make the company brands "difficult, if not impossible, to see." They claim the 2009 law violates their right to free speech. A spokesperson for Altria, which owns Philip Morris, said in an e- mail that the company is reviewing the new images but made no further comment.

Before selecting the nine images, the FDA conducted studies involving 18,000 participants - including children, pregnant women, and seniors - to determine which graphics had the most powerful effects.

An estimated 47 million people smoke in the United States, and nearly half a million die every year of smoking-related causes. In Massachusetts, more than 8,000 residents die each year from the effects of smoking, and 1,000 or more die from the effects of secondhand smoke, according to the state Department of Public Health.

On the streets of Boston, the new warnings received a mixed reaction from smokers. "This is gross," said 24-year-old makeup artist Stephanie Johnson as she flipped through printouts of the nine images with a Camel between her fingers. "I don't think it's really that necessary."

Johnson's first memory of cigarettes is her aunt's box of Newports, always resting on a coffee table or countertop during family functions. Had those boxes included a picture of a corpse, Johnson acknowledged, she might have thought twice before she began smoking in college.

"I would have thought, `That's the gross stuff that makes your lungs icky,' " she said.

But Christopher Comeau, who started smoking when he was 12, doesn't think the labels would have had any impact on him. "I already know it's bad for me. But I do it anyway," he said and reached for his pack of cigarettes. "Now I want another one."

Deborah Kotz can be reached at dkotz@globe.com.

TOXIC SMOKE NEW CIGARETTE PACKS STRIP THE GLAMOUR AWAY

22 June 2011

Pittsburgh Post-Gazette

© 2011 Post Gazette Publishing Company. Provided by ProQuest Information and Learning. All rights reserved.

New warning labels that will be displayed on cigarette packs next year are as obnoxious as a thick puff of smoke in the face or a clump of ashes on a dinner plate. And that's the intention.

The U.S. Food and Drug Administration selected graphic warnings, which will cover the top half of both the front and back of cigarette packs, because they effectively depict the health hazards associated with smoking and second-hand smoke.

Each of the nine warnings contains a picture and a consequence of smoking. The one that says "Cigarettes are addictive" is accompanied by a photograph of a man holding a cigarette as smoke puffs out of a surgical incision in his throat. "Cigarettes cause cancer" comes with a photo of diseased teeth and lips. "Cigarettes cause fatal lung disease" includes photos of pink, healthy lungs next to a blackened, decaying set. And "Smoking can kill you" is illustrated with a photo of a body after an autopsy.

Each label will include a toll-free phone number, 1-800-QUIT-NOW (784-8669), for information and help in quitting.

Also affected will be cigarette advertisements, which must include the warnings on the top and cover at least 20 percent of their display space.

The FDA relied on up-to-date scientific literature in crafting the messages, the first change in cigarette pack warnings in 25 years. The unsettling labels will be required starting in September 2012 because of the bipartisan Family Smoking Prevention and Tobacco Control Act of 2009.

Despite study after study that demonstrates tobacco use is the leading cause of premature, preventable death in this country, smokers still underestimate the severity of health risks. According to the Campaign for Tobacco-Free Kids, though, studies throughout the world have proven that pictorial warnings are most effective in discouraging children and others from starting to smoke and in motivating smokers to quit.

These new labels offer a strong, visual rebuttal to efforts by tobacco companies to entice smokers with slick advertisements.

Labels frankly depict health risks of smoking, federal health secretary says

By Richard Craver, Winston-Salem Journal, N.C.

McClatchy-Tribune Regional News

22 June 2011

Winston-Salem Journal (MCT)

Distributed by McClatchy-Tribune Information Services.

June 22--A cadaver with a sewn-up chest. Diseased lungs and gums. Cigarette smoke drifting around an infant.

Those are four of the nine graphic warning labels the Food and Drug Administration has chosen to place on cigarette packs and cartons and with cigarette advertising.

They are slated to debut in September 2012. The FDA said it is the most significant change to the labeling of cigarette packaging in 25 years.

The labels will appear on the top half of packs and take up 20 percent of an ad.

"These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit and prevent children from smoking," said Kathleen Sebelius, the secretary of the U.S. Health and Human Services Department.

According to the Centers for Disease Control and Prevention, tobacco use is the leading cause of premature and preventable death in the United States, responsible for 443,000 deaths each year.

It's not certain, however, that the images will roll out as planned.

A federal lawsuit was filed against the FDA in August 2009 by a group of tobacco manufacturers and retailers, led by R.J. Reynolds Tobacco Co., American Snuff Co., Lorillard Inc. and Commonwealth Brands Inc.

The companies say they are trying to "protect their First Amendment right to communicate with adult tobacco consumers about their products." In a January 2010 filing, the manufacturers argued the anti-smoking message is "ideological" in nature.

They also said larger warning labels would make cigarette branding difficult to see and hurt the value of their trademarks. David Howard, a spokesman for Reynolds, said the company does have "processes in place to effectively manage" the potential future display of cigarette packs at retail.

How effective the labels will be also is uncertain.

An FDA study, released in October, found putting more graphic warning labels on packs may stir the emotions of smokers, but it might not spur them to quit.

The study involved 9,575 smokers ages 25 and older, 4,584 smokers ages 18 to 24 and 4,600 ages 13 to 17 who either smoke or were considering starting.

Smokers were shown each image for as long as they wanted to look at it, but couldn't go back once they went to the next graphic. They were contacted a week later to determine their recall of the images and warnings.

The FDA said several images drew emotional and cognitive reactions when viewed and also were recalled distinctly. Some in-your-face images, however, either were not as well recalled or drew limited reaction.

"Responses vary somewhat by age, suggesting a one-size-fits-all strategy for the graphic warning labels might not be optimal," the report said.

Bill Godshall, the executive director of SmokeFree Pennsylvania, said having the warnings in color will resonate more with some smokers.

"To be more helpful, the FDA should also require warnings to inform smokers that all cigarettes are similarly hazardous, that smoke-free alternatives are far less hazardous than cigarettes, and that most ex-smokers quit cold turkey after multiple attempts," Godshall said.

Matthew Myers, the president of the Campaign for Tobacco-Free Kids, said the labels "represent a milestone in the fight against tobacco use in the United States."

"With these warnings, the United States is catching up to scientific best practices and joining 43 countries that already require large, graphic cigarette warnings," Myers said.

John Sweeney, the director of the sports-communication program at UNC Chapel Hill, said the images should jostle smokers who have become numb to the original surgeon general's warning.

However, he questioned how effective the images will be to addicted smokers and youths desensitized by media images.

"It is hard to understate the powerful impact that pictures of Linda Blair as the child possessed in 'The Exorcist' made when the film was first released," Sweeney said.

"I now see those same images without any sense of horror or revulsion. They are just nostalgia, as surreal as that may seem.

"Best wishes to the FDA for success," he said. "But their work will not be done with the release of these images."

Graphic cigarette labels: Public health necessity or free speech violation?

By John Reid Blackwell, Richmond Times-Dispatch, Va.

McClatchy-Tribune Regional News

22 June 2011

Richmond Times-Dispatch (MCT)

Distributed by McClatchy - Tribune Information Services

June 22--Diseased lungs and rotten teeth. A man with a hole in his throat. A crying infant. A body with an enormous surgical scar on its chest.

Those and other blunt images are part of nine different warning labels that must cover the top half of the front and back of all cigarette packs sold in the United States starting in September 2012.

The graphic health warnings, required under a federal law passed in 2009, are the biggest change to cigarette packaging in the U.S. in a generation. While praised by public-health groups, the mandate already has set off a legal challenge by some tobacco companies who argue that it interferes with their freedom of speech.

The labels also are the most publicly visible step taken so far by the U.S. Food and Drug Administration to flex its regulatory power over tobacco products, an authority granted to the agency by Congress and President Barack Obama two years ago.

"We are trying to communicate accurate, truthful information about the health impact of smoking, to allow consumers to be informed," Dr. Lawrence Deyton, director of the FDA's Center for Tobacco Products, said in an interview Tuesday.

As required by the federal law, the agency already has implemented other measures such as banning the use of the descriptors "light" and "low-tar" on cigarette packaging, on the grounds that those terms are misleading. It also has banned the sale of fruit- and candy-flavored cigarettes, and it may restrict the use of menthol flavoring.

"This is, of course, a very important and very visual change," Deyton said of the graphic warning labels. "This will create a very different cigarette pack and advertising in this country when the (warnings) are in place."

The warning labels also must cover 20 percent of any cigarette advertisement. Each warning will be used on a rotating basis.

The FDA chose the final nine warning labels, which were publicly announced Tuesday, from among 36 proposed labels it presented for public comment in November. The agency received more than 1,700 public comments on the proposed warnings, including comments from the tobacco industry.

Spokesmen for the two largest U.S. cigarette companies -- Henrico County-based Altria Group Inc. and Winston-Salem N.C.-based Reynolds-American Inc. -- declined to comment on the warning labels Tuesday.

Yet tobacco companies have made their unhappiness with the requirements known.

Reynolds already has challenged the warning labels and other aspects of FDA regulation in court. In September 2009, Reynolds and several smaller companies filed a federal lawsuit claiming it is unconstitutional to force them to use larger warning labels that the companies said make them "stigmatize" their own products.

In January, a federal judge in Kentucky overturned two provisions of the FDA law but upheld most of the law's cigarette advertising restrictions and warning labels mandate. The companies have appealed, with oral arguments scheduled for July 27 in the 6th U.S. Circuit Court of Appeals.

Altria Group, the parent company of cigarette maker Philip Morris USA, is not part of that lawsuit. The company supported FDA regulation of tobacco products.

However, Altria has said in comments submitted to the FDA that it, too, believes that the warning label mandate violates its First Amendment rights.

"Any government requirement that compels a private entity to carry a message not of its own choosing raises constitutional concerns," the company wrote in a submission to the FDA in January.

Smaller tobacco companies also will be affected.

"The problem we see, of course, is it substantially reduces the ability of any manufacturer to brand their cigarettes and make them unique," said Everett Gee, vice president and general counsel for S&M brands, a family-owned, regional cigarette maker in Lunenburg County that makes the Bailey's brand of cigarettes.

"There is going to be some significant expense in the design of the packaging and advertising materials to come into compliance with the new regime, for sure," Gee said. "It is going to be rough for us to swallow, but we will comply with the FDA's requirements," he said.

Tobacco-control groups on Tuesday praised the graphic warning labels as a needed public-health measure already adopted by more than 40 other nations.

"These new warnings will tell the truth about how deadly and unglamorous cigarette smoking truly is," the Campaign for Tobacco-Free Kids said.

Smoking-related diseases cause about 443,000 deaths a year in the U.S., according to government estimates.

Warning labels saying "Cigarettes may be hazardous to your health" first appeared by federal mandate in 1965. The current warning saying smoking can cause lung cancer was put on cigarette packs in the 1980s.

The impact of the new graphic warning labels on smoking rates is difficult to determine, but some research has indicated that it does help change smokers' attitudes about health risks.

The FDA said it estimates that the warnings will reduce the number of smokers by 213,000 in 2013, with smaller additional reductions through 2031, still only a fraction of the 46 million smokers in the U.S.

The estimates were reached by looking at how smoking rates in Canada were affected when it required larger cigarette warning labels, Deyton said.

"I do think reducing the number of smokers by 213,000 in one year is a significant impact," Deyton said. "It certainly has an impact on those individuals and their families and on the economy."

Deyton said one of the most important steps the FDA took was to require the addition of a toll-free phone number to the labels that smokers can call to get advice on quitting. He said that was not required by the legislation granting FDA regulatory power over tobacco products.

"A smoker will one day pick up a pack, see the warning, and hopefully notice the (phone) number," he said. "If that is the day the smoker decides they want to quit, they will have a number right there that will give them individual support and help quitting."

Warning labels for cigarette packs take a grisly turn. Will they work?

Ron Scherer Staff writer

21 June 2011

The Christian Science Monitor

© 2011 Christian Science Monitor. Provided by ProQuest Information and Learning. All Rights Reserved.

Warning labels unveiled by the FDA would be the first change to cigarette pack warnings in 25 years. Nine graphic images were chosen using consumer surveys that involved 18,000 people.

Announcing the first change to cigarette pack health warnings in 25 years, the US Food and Drug Administration unveiled nine graphic warning labels Tuesday that cigarette companies will be required to print by the fall of 2012 on the top half of every cigarette pack and 20 percent of every poster or ad.

Some of the images are grisly - showing the top half of a cadaver after an autopsy - and designed to perhaps shock smokers into quitting. Others are somewhat educational, showing smoke drifting toward a young child's face with a warning that tobacco smoke can harm your children. And, every pack will contain the 800 number to call for help quitting smoking.

"This represents the most dramatic change in the history of the United States efforts to curtail smoking, because it's the first time health warnings on smoking were selected because of effectiveness instead of political acceptability," says Matthew Myers, president of the Campaign for Tobacco-Free Kids in Washington.

But, will it make any difference once the warnings are in place? They are supposed to be slapped on by October 2012, although tobacco companies are contesting the new regulations in court.

According to Margaret Hamburg, the commissioner of Food and Drugs, economists at the agency calculate 213,000 smokers will quit in the first year. "That does not start to calculate the number who choose not to start smoking," says Ms. Hamburg in an interview.

Although this number represents only half of 1 percent of the 40 million smokers in the US, antismoking advocates say it could save 60,000 to 70,000 lives if the tobacco-users quit for good. "Very few actions save 70,000 lives," says Mr. Myers.

Images chosen after consumer surveys

The nine images are the result of what Ms. Hamburg terms one of the largest consumer surveys, in which 18,000 people were asked for their impressions of the warning labels. "We collected a lot of information and I think we will see an increased awareness," she says, "Importantly, they will discourage individuals who are not yet smokers from becoming smokers."

Already some 43 countries have graphic warnings. However, even advocates for the images say there are no conclusive studies that show a direct correlation between the ads and individuals quitting smoking.

"In every instance, there was an increased awareness, an increased sense of the real dangers of smoking and a significantly increased motivation for quitting," says Myers. "But, it's very hard to measure precisely how many quit because of the addition of warning labels."

According to an FDA public comment filing by antismoking advocates, pictorial warning labels introduced in Australia in 2006 made 57 percent of smokers think about quitting, helped 36 percent of smokers reduce their consumption, and helped 34 percent of smokers try to quit.

Old warnings lost their impact

Although US cigarette packs already contain health warnings, they have not changed in 25 years, points out Ms. Hamburg. "After 25 years we know they no longer have much impact," says Hamburg.

In order to avoid having the same thing happen to the graphic images, Hamburg says the FDA will study consumer responses, adding new images and health warnings to make sure people don't become "inured" to the new images.

Antismoking advocates don't expect the new images to significantly cut down on smoking unless Congress or the states fund more smoking-reduction efforts.

"The Lung Association has called attention to the need for increased funding for state quit lines so as people see these images in 2012, there is someone to answer the phone," says Erika Sward, director of National Advocacy for the American Lung Association in Washington.

She says reducing smoking will help rein in health-care costs, which now come to $96 billion per year to treat smokers for such diseases as lung cancer and heart attacks. "A large burden of that is in the Medicaid population," she says, referring to those who are too poor to afford health insurance.

The new images are the result of tobacco regulations passed by the Democratic controlled Congress in 2009 and supported by the Obama administration.

Six tobacco companies filed suit

Although the new images are supposed to go into effect by October of 2012, six tobacco companies sued the government in a federal district court in Kentucky in 2009 over the new law. Among their challenges, the companies claimed the new regulations interfered with their freedom of speech rights by forcing their names to appear on the bottom of the pack.

The court struck down a government ban on color and graphics on tobacco labels and a government ban on claims by tobacco companies implying that a tobacco product is safer because of FDA regulation and approval.

However, the court upheld the requirement for large graphic warnings on tobacco packages.

The decision is being appealed by the companies. The Sixth Circuit Court of Appeals in Cincinnati is scheduled to hear oral arguments on July 27.

At the hearing, the companies can ask the federal appeals court for an injunction to prevent the new rules from going into effect until the court rules, says John Banzhaf, special counsel for Action on Smoking and Health and a public interest law professor at George Washington University in Washington.

The tobacco companies "could win and the new rules would not go into effect or the litigation is more likely to delay them," he says. He says the industry may take the case all the way to the US Supreme Court if they lose.

"That would add at least another year of delay and the whole process would certainly take more than 15 months," he says. "The courts usually take the view of not disturbing the status quo until the case is decided, in which case an injunction is quite possible."

US unveils graphic cigarette warnings

Kerry Sheridan

21 June 2011

Agence France Presse

Copyright Agence France-Presse, 2011 All reproduction and presentation rights reserved.

A lifeless body, a scarred mouth and a blackened lung were among the graphic images in a new set of cigarette warnings unveiled Tuesday by the US government to highlight the health risks of smoking.

The warnings will occupy the top 50 percent of the front and rear panels of cigarette packs sold in the United States and the top 20 percent of cigarette advertisements beginning in September 2012, the Food and Drug Administration announced.

The nine color images, which can be seen at fda.gov/cigarettewarnings, mark the first change in cigarette warnings in more than 25 years and are "a significant advancement in communicating the dangers of smoking," the agency added.

One of the images, which shows a man with his chest sewn up, bears the caption "Warning: Smoking can kill you." According to the FDA, smoking kills 1,200 people a day in the United States alone.

Another picture shows a close-up of a mouth filled with scattered, brown teeth and a lip with an open sore, warning: "Cigarettes cause cancer."

"We want kids to understand smoking is gross, not cool, and there is really nothing pretty about having mouth cancer," Health and Human Services Secretary Kathleen Sebelius said at the White House in a briefing to unveil the warnings.

Smoking causes 90 percent of all lung cancer in men and 80 percent in women, and has been linked to several other cancers, the FDA said.

The new labels also seek to warn pregnant women and new parents of the dangers of smoking, with a drawn image showing a premature baby in a hospital incubator and a picture showing a real baby staring at a plume of smoke.

"This will be a dramatic change in what a cigarette package looks like, no doubt about it. These warning labels are very graphic. They are large," said FDA commissioner Margaret Hamburg.

"It will change the consumer response to a packet of cigarettes and frankly that is what we want," she said, adding that a pack-a-day smoker would see the warnings 7,000 times in a single year.

However, the tobacco industry has filed a lawsuit challenging the labels, saying they put undue restrictions on tobacco companies' right to free speech by confiscating too much of the packet space.

"Even on acute poisons (e.g., pesticides and toxic chemicals), the warnings are not of this size and character," said comments submitted to the FDA in January by RJ Reynolds Tobacco Company, Lorillard Tobacco Company, and Commonwealth Brands, Inc.

"It is therefore quite clear that the intended function of the proposed 'warnings' is not to warn consumers about the risks from smoking, but to communicate a government message: 'Don't buy or use this product.'"

An RJ Reynolds spokesman told AFP the company had no further comment.

"Regarding our lawsuit challenging certain provisions of the FDA law, including graphic warnings, oral arguments are scheduled for July 27th in the 6th Circuit Court of Appeal (in Cincinnati)," spokesman David Howard said in an email.

The label changes came about following a June 2009 law, signed by President Barack Obama about five months after he took office, that gave the FDA the power to regulate manufacturing, marketing and sale of tobacco products.

The nine images were picked from a group of 36 proposals issued several months ago, after health authorities analyzed results on their effectiveness from an 18,000-person study and took into account about 1,700 public comments, the FDA said.

Each warning label also contains a phone number to call for help in quitting.

Anti-smoking groups such as the Campaign for Tobacco-Free Kids hailed the announcement as "the most significant change in US cigarette warnings since they were first required in 1965."

"The large, graphic warnings will be impossible to miss and represent a dramatic advance over existing text warnings," the group said in a statement.

Currently, the standard warning on cigarette packs in the United States is found in small print along the side: "Surgeon General's warning: cigarette smoke contains carbon monoxide."

About 20 percent of the US population smokes, according to the Centers for Disease Control and Prevention.

Similar graphic warnings can be seen on cigarette packs from Brazil to Britain and beyond, showing vivid pictures of rotting teeth, throat cancer, premature babies and heart surgeons operating on clogged arteries.

Questions linger whether new cigarette health warning labels must be 'gross' to be effective

By MICHAEL FELBERBAUM

AP Tobacco Writer

22 June 2011

(c) 2011. The Associated Press. All Rights Reserved.

RICHMOND, Va. (AP) - You may think an image of rotting teeth and a mouth lesion are gross. But the U.S. government says it's just what you need to kick the habit.

Cigarette packs in the U.S. will soon feature new warning labels with graphic images of the negative health effects of smoking, including diseased lungs and the sewn-up corpse of a smoker. The U.S. government hopes the new warnings will discourage smoking, but smokers and nonsmokers alike question whether the ads are too gory.

"Somebody said when they first saw the warnings, `These are really gross.' And they are," FDA Commissioner Margaret Hamburg said at a White House briefing. "We want kids to understand smoking is gross ---- not cool ---- and there's really nothing pretty about having mouth cancer."

The labels, which were released on Tuesday, are a part of a campaign by the Food and Drug Administration that aims to convey the dangers of tobacco, which is responsible for about 443,000 deaths in the U.S. a year.

The warnings, which must appear on cigarette packs by the fall of 2012, include several images that could be seen as shocking to some ---- and disturbing to others. Among the images: A man with a tracheotomy smoking, a mother holding her baby with smoke swirling around them and a man with an oxygen mask. The labels also feature phrases like "Smoking can kill you" and "Cigarettes cause cancer." They will take up the top half -- both front and back -- of a pack of cigarettes and be featured in advertisements.

Some consumers on Tuesday said that they were concerned that the images on the new labels were too explicit for children and others who might come across them in store aisles.

Zenobia Marder, a nonsmoker and high school student from New York City, was startled when she looked at some of the labels. "Oh my God!" screamed the 15-year-old.

Ashley Johnson, 21, of Cincinnati, had a similar reaction. "They look so bad," says Johnson, who has been smoking for about a year. "I think that when people see these pictures, they might put the cigarettes back and get something else instead."

Warning labels first appeared on U.S. cigarette packs in 1965, and current warning labels that feature a small box with text were put on cigarette packs in the mid-1980s. Changes to more graphic warning labels that feature color images of the negative effects of tobacco use were mandated in a law passed in 2009 that, for the first time, gave the federal government authority to regulate tobacco.

Tobacco companies and others have argued graphic warnings like the nine new labels may cross the line of social acceptability.

In comments to the FDA, some tobacco companies argued the "shock and awe" of the labels have been used in numerous ideological debates like when anti-abortion protesters display photographs of aborted fetuses or animal-rights activists display photographs of mutilated animals.

"Although such images illustrate actual effects of abortions and actual animal treatment, no one would contend that they are `purely factual and uncontroversial,'" Reynolds American Inc., parent company of America's second-largest cigarette maker, R.J. Reynolds; No. 3 cigarette maker Lorillard Inc.; and No. 4 cigarette company Commonwealth Brands Inc., told the FDA. The companies also are part of a federal lawsuit that in part deals with the legality of the new labels.

Cigarette labels with more graphic images could also concern some retailers; customers who may be offended or disgusted by the packs behind the counter may take their business elsewhere.

"You're going to run into people that will not necessarily like this," said Jeff Lenard, spokesman for the National Association of Convenience Stores, a group representing an industry that gets about 160 million transactions each day. "When somebody's hungry, they get something to eat. When somebody's thirsty, they get something to drink, and we just want to make sure that when they go in, they still want to get that."

Health and Human Services Secretary Kathleen Sebelius acknowledged that the labels are "frank, honest and powerful depictions" aimed at making tobacco-related death and disease part of the nation's past. Marketing and tobacco control experts say that's what's needed.

"It's clear to us that the stronger, the more graphic, the better," said Jeremy Kees, a marketing professor at the Villanova School of Business who has done studies on graphic cigarette warning labels. "Fear really drives the effectiveness of these warning labels ... mild, weak images are, in some cases, no better than a plain text warning."

Marketing experts also say the new labels aren't unique to the U.S. In fact, the new U.S. labels are typical of what's being used in the more than 40 other countries, said Stanton Glantz, a tobacco researcher at the University of California at San Francisco. Canada, for instance, in 2000 rolled out warning labels to include a pregnant woman smoking. Uruguay also shows rotting teeth and gums on its labels, similar to the images on the new warning labels in the U.S.

"These are the images that work," Glantz said. "What the research shows is that images that evoke a strong emotional response are the best ones."

------

Associated Press Writers Joseph Pisani in New York and Lisa Cornwell in Cincinnati contributed to this report.

FDA unveils warning signs 9 graphic images to be displayed on cigarette packages

By Melissa Healy, Tribune Newspapers

22 June 2011

Chicago Tribune

Copyright 2011, Chicago Tribune. All Rights Reserved.

With the unveiling of nine images that will adorn every package of cigarettes starting in fall 2012, government officials and outside experts predict there will be an initial wave of smokers seeking help in quitting, but caution that regulators will have to step up the impact of their message as U.S. consumers grow accustomed to the warnings.

The labels released Tuesday are "an important and powerful tool" in the fight to reduce tobacco-related disease and death, said Food and Drug Administration Commissioner Margaret Hamburg. She estimated the images could induce as many as 213,000 of the nation's 46 million cigarette smokers to quit in the first year of the campaign. The American Lung Association warned local quit lines to brace for a deluge of phone calls.

Hamburg and other officials stressed that the FDA will continue to study the effect the images have on the public and will likely update them yearly in an effort to keep the message fresh in consumers' minds. Outside experts said the government will have to vary its messages to avoid what psychologists call "wear out."

The nine images chosen by the FDA -- the first update to cigarette-package warnings in a quarter century -- are stark and often disturbing, and each is accompanied by simple text informing cigarette buyers of the known consequences. One of the nine images appears to depict a recently autopsied cadaver and states, "Smoking can kill you."

Other warnings make an appeal to smokers' concern for others, an approach that research has found effective in getting smokers to try quitting. In one, a toddler clutching the chest of an adult gazes at a nearby swirl of smoke. The message reads, "Tobacco smoke can harm your children."

Only one of the images conveys hope and encouragement to the dwindling number of Americans who cling to the habit. In it, a 30-something man pulls open his shirt to reveal a T-shirt that declares, "I Quit." The text reads, "Quitting smoking now greatly reduces serious risks to your health."

The initiative is the most dramatic of the steps taken by the FDA since the 2009 Family Smoking Prevention and Tobacco Control Act gave the agency expanded regulatory powers over tobacco. It is also the first time in 25 years that the health warnings on the packaging of tobacco products has been updated beyond the statement, in small type, that the Surgeon General of the United States has determined cigarette smoking to be harmful to human health.

The new warnings didn't impress everyone Tuesday.

"They're obnoxious," said Bob Kohl, a 60-year-old California smoker who was diagnosed two years ago with emphysema and has quit three times. "They are insulting. They are very specifically condescending, which irritates me."

In requiring the warnings, the United States joins some 40 other countries that already require cigarette packaging to carry prominent warnings on the dangers of smoking. Canada and Europe pioneered the practice, and several developing countries, including India, Malaysia, Mauritius, Thailand and Uruguay, have preceded the United States in requiring such graphic anti-smoking messages.

Starting Sept. 22, 2012, the images and related text will cover the top half of each cigarette package sold in the United States, making them "new mini-billboards for prevention," said Dr. Howard Koh, assistant secretary for health at the Department of Health and Human Services.

The images were culled from a group of 36 candidates circulated for public comment starting in June 2010 by the FDA.

In choosing the nine labels, the agency ruled out a number of far more disturbing images, including an unsparing photograph of a bald lung cancer victim hollowed out by her disease.

During the months-long comment period, experts urged the FDA to add a toll-free number to each image that will lead callers to help with quitting. The FDA acted on the recommendation, affixing the tagline "800-QUIT-NOW" to each image. \ ----------]\ mhealy@tribune.com


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